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A  CLINfSAiTpTinY 
OF  THE  SWJIOU^ND/^RULENT 


^     ,^ISEASES 
OFV^^E   LABYRINTH 

BY 

DR.  ERICH  RUTTIN 

Privatdocent  in  the  Otological  Clinic,  University  of  Visnna 
WITH  A  FOREWORD  BY 

PROFESSOR  DR.   VICTOR  URBANTSCHITSCH 

AUTHORIZED  TRANSLATION  BY 

HORACE  NEVVHART,  A.B.,  M.D., 

Instructor  in  Otology,   University  of  Minnesota:  Otologist  and  Rhinologist,  North- 
western Hospital;  Fellow  American  Academy  of  Ophthalmology  and 
Oto-Laryn  gology;  Fellow  American  College  of  Surgeons,  etc. 

WITH  25  TEXTUAL  FIGURES 


NEW  YORK 

REBMAN  COMPANY 

Ul-145  WEST  36th  STREET 


Copyright,  1914,  by 
REBMAN  COMPANY 

OF  New  York 


PRINTED  IN  AMERICA 


iMHfiea! 
ILinr/ 


TRANSLATOR'S   PREFACE 

This  translation  of  Dr.  Ruttin's  Klinik  der  serosen  und 
eitrigen  Lahyrinth-Entzundungen  has  been  made  in  re- 
sponse to  the  persistent  demand  on  the  part  of  many  Ameri- 
can and  English  students  of  otology  who  have  followed  the 
author  in  the  Vienna  clinic  and  who  wish  to  possess  the 
monograph  in  their  own  language. 

Others,  both  otologists  and  general  practitioners,  who 
are  not  familiar  with  recent  progress  in  the  diagnosis  and 
treatment  of  labyrinthine  complications  will  find  it  a  prac- 
tical treatise  upon  the  subject,  which  should  prove  a  useful 
guide  in  dealing  intelligently^  with  those  cases  of  labyrinth 
involvement  which  are  constantly  appearing  in  practice, 
but  which  until  very  recently  have  too  often  been  unrecog- 
nized or  misinterpreted. 

The  original  text  has  been  closely  followed,  though  the 
case  histories  have  been  somewhat  abbreviated. 

Horace  Newhart. 

910  Donaldson  Building,  Minneapolis,  Minnesota.  • 


111 


iM}fK*^a^ 


FOKEWORD 

Diseases  of  the  labyrinth  have  at  the  present  time  become 
the  center  of  interest  among  otologists,  and  jnstly  so,  for 
the  recognition  of  diseases  of  the  labyrinth  claims  our 
closest  consideration,  not  only  because  of  the  functional  im- 
portance of  this  organ,  but  also  because  of  the  vital  signifi- 
cance of  an  extension  of  an  inflammatory  process  from  the 
labyrinth  into  the  cranial  cavity.  It  may  be  stated  here 
without  presumption  that  the  Vienna  school  has  very  mate- 
rially advanced  our  knowledge  concerning  the  normal  and 
diseased  labyrinth,  particularly  of  the  vestibular  appa- 
ratus, and  possesses  a  valuable  experience  as  regards  the 
therapy  of  the  labyrinth. 

Naturally  the  establishment  of  basic  principles  in  re- 
gard to  the  diagnosis  and  treatment  of  the  various  affec- 
tions of  the  labyrinth  demands  still  further  exhaustive 
investigations  on  the  part  of  specialists.  And  from  this 
point  of  view  it  would  appear  justifiable,  because  of  its  large 
wealth  of  clinical  material,  that  the  present  position  of  the 
Vienna  school  of  otology  be  presented. 

My  assistant.  Dr.  Ritttin,  who  for  years  has  devoted  him- 
self zealously  to  the  study  of  diseases  of  the  labyrinth,  and 
to  whom  we  are  already  indebted  for  several  valuable  mono- 
graphs, presents  in  the  following  work  a  detailed  descrip- 
tion of  the  diseases  of  the  labyrinth,  in  which  the  functional 
manifestations  of  the  nonnal  and  diseased  labyrinth,  the 
different  clinical  aspects  and  the  therapeutic  considerations 
in  each  case  are  discussed  and  presented  in  a  manner  com- 
prehensible even  to  the  non-specialist. 

I  hope,  therefore,  that  this  book  will  receive  the  general 
notice  and  circulation  it  deserves,  and  that  it  is  destined  to 
yield  a  valuable  contribution  to  our  literature,  not  only  by 
way  of  enlarging  our  knowledge  of  labyrinthine  diseases, 
but  also  helping  to  clear  up  some  as  yet  unsettled  views  in 

Prof.  Dk.  Victob  Urbantschitsch. 

Vienna. 


CONTENTS 

PAGE 

Translator's   Preface iii 

Foreword v 

CHAPTER  I 

Functional  examination 1 

1.  Examination   of   the   cochlea 1 

2.  Examination  of  the  vestibular  apparatus 3 

A.  Definition 3 

B.  Direction  of  the  nystagmus 5 

C.  Degree  of  the  nystagmus 6 

D.  Production  of  nystagmus  by  means  of  physiological  stimuli  8 

1.  Rotation  or  turning  stimulus 8 

2.  Caloric  stimulus 18 

3.  Mechanical  stimulus    (fistula  test) 23 

E.  Relative  value  of  the  stimuli 24 

F.  Disturbances  of  equilibrium '     .      .      .      .  25 

CHAPTER  II 

Circumscribed,    diffuse    serous    secondary    and   diffuse   purulent 

labyrinthitis 28 

A.  Pathologj- 28 

B.  Etiology 31 

C.  Symptoms 34 

Circumscribed  labyrinthitis 35 

Diffuse  serous  secondary  labyrinthitis 36 

Diffuse  purulent  manifest  labyrinthitis 36 

Diffuse  purulent  latent  labyrinthitis 36 

Anamnesis 40 

Present  symptoms 41 

Tinnitus    aurium 41 

Nystagmus 43 

Hearing 44 

Caloric   reaction 45 

Rotation  or  turning  test 46 

Fistula  test ^  51 

D.  Fever 55 

E.  Therapy,  i.e.,  the  indications  for  the  radical  and  the  labyrinth 

operations 59 

Indications , 59 

Circumscribed   labyrinthitis       ...          60 

Diffuse  serous  secondary  labyrinthitis 63 

Diffuse  purulent  manifest  labyrinthitis 64 

Diffuse  purulent  latent   labyrinthitis 65 

Technie  of  the  labyrinth  operation 67 

vii 


viii  CONTENTS 

PAGE 

F.  Termination 73 

Circumscribed  labyrinthitis 73 

Diffuse  serous  secondary  labyrinthitis 74 

Diffuse  purulent  manifest  labyrinthitis 74 

Diffuse  purulent  latent  labyrinthitis 75 

CHAPTER  III 

Injuries  of  the  labtrinth 77 

G.  Statistics 81 

CHAPTER  IV 

Serous  induced  i^abyrinthitis 85 

CHAPTER  V 

Labyrinthitis  and  brain  abscess 91 

Case  histories 98 

Index 231 


CHAPTER  I 
FUNCTIONAL    EXAMINATION 

Since  we  have  united  in  the  labyrinth  two  organs  each 
having  a  different  function,  the  cochlea  and  the  vestibular 
apparatus,  so  the  functional  examination  must  include  both 
organs  separately. 

It  is  advantageous  to  take  up  the  functional  tests  accord- 
ing to  a  scheme  which  we  use  at  the  clinic  as  follows : 

Cochlear  Examination 
Right  Left 

Conversational  Voice 
AVhispered  Voice 
Weber 
Rinne 
Schwabach 
C, 
C* 

Vestibular  Examination 

Spontaneous  Nystagmus 
Turning  or  Rotation  Reaction 
Fistula  Symptom 
Caloric  Reaction 
Galvanic  Reaction 

In  this  scheme  the  cochlear  and  the  vestibular  portions 
are  considered  separately. 

1.  Examination  of  the  Cochlea 

First  of  all,  attention  must  be  called  to  the  fact  that 
merely  closing  the  external  meatus  of  the  ear  not  under 
examination  so  poorly  excludes  it  from  participation  in  the 

1 


2  DISEASES  OF  THE  LABYBIMH 

act  of  hearing  that  results  olitained  by  this  method  are  not 
at  all  reliable.  The  recognition  of  this  element  of  uncertainty 
has  led  to  the  suggestion  of  various  aids,  particularly  for 
the  diagnosis  of  unilateral  deafness  (the  Lucae-Dennert  test, 
conversation  tube,  etc.).  These,  at  the  present  time,  have 
all  become  superfluous  through  the  invention  of  the  so- 
called  exclusion  apparatus.  Bdrdiiy,  by  means  of  a  loud 
intra-aural  noise,  has  entirely  excluded  the  ear  not  under 
examination.  We  now  employ  his  exclusion  apparatus 
(Laermapparat).  Other  forms  have  been  devised  by  Voss 
and  Neumann.    (See  Fig.  15a  on  page  27.) 

If,  on  applying  this  apparatus  to  the  ear  not  being 
tested,  the  loud  voice  next  to  the  ear  (ad  concham)  is  not 
heard,  we  may  assume  that  the  examined  ear  is  deaf  for 
speech.  Deafness  for  speech  alone,  however,  is  not  suffi- 
cient to  prove  that  the  cochlea  has  completely  lost  its  func- 
tion. For  this  purpose  we  must  also  ascertain  what  is  the 
perception  for  tuning  forks.  Our  common  tuning  fork  tests 
often  give  very  useful  clues,  even  though  they  are  not  suffi- 
cient to  prove  the  presence  of  complete  unilateral  deaf- 
ness. If,  in  Weber's  test,  there  is  lateralization  to  the 
healthy  side,  if  at  the  same  time  Rinne  is  co — (infinitely 
negative),  that  is,  if  the  tuning  fork  is  perceived  only  by 
bone  conduction;  if  the  deep  tones  (d)  are  not  heard  and 
tliere  is  preeent  a  shortening  for  high  tones  (C*),  then  the 
diagnosis  of  a  unilateral  total  deafness  is  very  likely.  The 
cardinal  tests  (Weber,  Rinne  and  Schwabach)  are  made 
with  a  fork  of  medium  pitch  (e). 

More  exact  than  tke  ordinary  test  is  the  examination 
according  to  Bezold's  method  by  means  of  the  continuous 
tone  series  of  Edelmann.  This  combination  of  tuning  forks 
aad  ^^'histlee  includes  the  entire  limit  of  perception  of  the 
human  ear  and  permits  of  the  determination  of  an  unal- 
tered or  altered  power  to  perceive  each  tone.  But  this  pro- 
cedure is  not  practical  of  execution  clinically,  for  it  con- 
sumes too  much  time. 

Bezold  has  himself  shortened  the  procedure  by  exam- 


FUNCTIONAL  EXAMINATION  3 

ining  up  to  C"  only  by  octaves,  and  from  there  on  by  quints. 
But  in  order  to  prove  Avith  certainty  a  unilateral  deafness, 
it  is  necessary  to  construct  a  so-called  tone  relief,  or  curve ; 
that  is  to  say,  the  tones  are  projected  upon  the  abscissa  and 
their  duration  upon  the  ordinate.  The  diagram  thus  ob- 
tained is  compared  with  that  of  the  normal  ear.  The  hear- 
ing curve  for  a  person  with  unilateral  deafness  begins  with 
a^  (if  the  other  ear  is  normal)  and  shows  a  rise  in  the  dura- 
tion with  the  pitch;  that  is,  a  relation  opposite  to  that  which 
is  found  in  the  normal  ear. 

Since  this  procedure  is  also  too  bothersome,  Wanner  has 
proposed  that  we  use  the  unweighted  a^  fork  with  a  duration 
of  ninety  seconds.  According  to  his  assertion,  if  this  fork 
is  not  heard  by  air  conduction  by  the  ear  under  examina- 
tion, we  may  assume  total  deafness  for  this  side. 

Another  very  simple  procedure  has  been  proposed  by 
Bdrdny.  If  we  touch  the  promontory  (of  course,  through  a 
perforation  in  the  membrane)  with  a  probe  whose  end  is 
in  contact  with  a  vibrating  tuning  fork,  a  person  with  even 
a  very  high  degree  of  deafness  will  perceive  the  sound  of 
the  fork.  One  who  is  totally  deaf  will  not  react,  for  this 
tone  is  not  transmitted  to  the  opposite  side. 

Further,  Neumann  has  endeavored  to  utilize  bone  con- 
duction to  determine  unilateral  total  deafness.  The  sound 
of  a  vibrating  tuning  fork  placed  upon  the  mastoid  of  the 
tested  ear  is  influenced  both  as  to  intensity  and  timbre  by 
closure  of  the  external  meatus  of  the  sound  side,  but  not 
when  the  meatus  of  the  affected  side  is  closed. 

2.    Examination  of  the  Vestibular  Apparatus 

The  vestibular  apparatus  reacts  to  the  movement  of  its 
lymph  by  a  reflex  movement  of  the  eyes  which  we  call 
nystagmus. 

A.  DEFINITION 
Nystagmus  is  a  rhythmic,  associated  movement  of  both 
eyeballs;  rhythmic,  because  it  consists  of  two  regular  com- 


4  DISEASES  OF  THE  LABYKIXTH 

poDents,  following  each  other  in  sequence,  the  one  quick, 
the  other  slow;  associated,  because  both  eyeballs  regularly 
I^articipate  in  the  movement.  We  said  a  quick  and  a  slow 
movement,  though  it  would  be  more  correct  to  say  a  slow 
and  a  quick  movement. 

Bdrdny  demonstrated  that  the  slow  component  is  the 
vestibular,  the  quick  component  is  the  opposing  movement 
of  central  origin.  Let  us  assume  that  my  right  vestibular 
apparatus,  in  consequence  of  a  stimulus  (irrigation  with 
cold  water,  for  example),  would  have  the  tendency  to  draw 
my  eyes  to  the  right;  then  the  eyeballs  would  move  from 
position  a  to  position  h. 


Right 


Left 


'    VS 


Fig.  1 


This  occurs  in  the  case  of  an  unconscious  person  or  one 
under  general  anaesthesia.  In  the  conscious  individual,  as 
soon  as  the  labyrinth  sends  out  its  reflex  impulse  which 
causes  the  changed  position  of  the  eyeball,  the  centers  are 
notified,  whereupon  these  centers  send  out  an  energetic  im- 
pulse to  counteract  the  impulse  from  the  labyrinth,  the  re- 
sult of  which  is  to  turn  the  eyeball  quickly  in  the  opposite 
direction. 

The  slow  labyrinthine  movement  was  not  observed  (be- 
cause of  its  slowness),  and  we  assume  the  quick  movement 
of  central  origin  to  be  the  first.  But  since  the  labyrinthine 
stimulus  continues,  the  same  action  and  corresponding 
counter  movement  are  repeated. 

This  struggle  between  labyrinthine  and  central  impulses 
continues  in  a  to  and  fro  movement  as  long  as  the  labyrinth 


FUNCTIOXAL  EXAMINATION  5 

irritation  exists  and  finds  its  expression  in  the  continuous 
rhythmic  exchange  of  a  quick  and  a  slow  eye  movement. 

The  greater  conspicuousness  of  the  quick  component  was 
the  reason  for  originally  designating  the  direction  of  the 
nystagmus  according  to  the  direction  of  the  quick  com- 
ponent, although  it  would  be  more  logical  to  designate  it  by 
the  direction  of  the  slow  component.  Thus  we  have  come 
to  speak  of  a  nystagTaus  whose  quick  component  is  directed 
to  the  left,  as  a  nystagmus  to  the  left,  and  a  nystagmus 
whose  quick  component  is  to  the  right,  as  a  right 
nystagmus. 

B.  DIRECTION  OF  THE  NYSTAGMUS 
From  the  suspension  (Cartesian)  of  the  eyeball,  it  fol- 
lows that  the  eye  is  capable  of  free  movement  in  the  three 
planes  of  space.  The  three  semicircular  canals  are  like- 
wise placed  approximately  in  the  three  planes  of  space. 
Flourens  discovered  the  remarkable  fact  that  each  semi- 
circular canal  has  the  power  to  provoke  reflex  movements 
of  the  eye  in  a  direction  corresponding  to  its  own  plane 
as  situated  within  the  cranium ;  that  is,  the  horizontal  canal 
produces  horizontal  nystagmus,  the  frontal,  frontal,  and 
the  sagittal  canal,  sagittal  nystagmus. 

The  horizontal  nystagmus,  for  example,  to  the  left,  ap- 
pears as  a  quick  movement  to  the  left  and  a  slow  move- 
ment toward  the  right. 

Right  Left 


Fig.  2 
The  smooth  arrow  indicates  the  quick  movement;  the  feathered  arrow,  the 
slow   movement. 

The  rotatoiy  nystagmus,  for  example,  to  the  left,  ap- 
pears to  us  as  a  quick  movement  of  the  eyes  in  the  frontal 
plane,  with  inclination  of  the  meridian  to  the  left  and  a 
slower  movement  backwards. 


6  DISEASES  OF  THE  LABYFINTH 

Nystagmus  in  tlie  frontal  plane,  however,  is  not  called 
frontal,  but  rotatory  nystagmus. 

Nystagnms  in  the  sagittal  plane,  for  example,  upward, 
appears  as  a  quick  movement  of  the  eyeballs  upward  with  a 
slow  downward  movement. 


Right 


Left 


Fig.  3 

a   represents   the   meridian;    6,    its    inclination.     The    arrows   indicate   the 
nystagmus  as   in  the  preceding  cut. 


Right 


Left 


Fig.  4 
The  arrows  have  the  same  meaning  as  in  the  two  preceding  cuts. 


C.   DEGREE  OF  THE  NYSTAGMUS 

We  must  assume  that  there  exists  a  certain  relationship 
between  the  stimulus  and  the  degree  of  the  nystagmus;  that 
is,  the  extent  of  the  movement  of  the  eyeball.  The  formula 
for  this  relationship  we  do  not  know,  though  we  may  as- 
sume, in  general,  the  greater  the  stimulus,  the  greater  the 
nystagmus. 

Inasmuch  as  all  attempts  to  make  a  direct  measurement 
of  the  nystagmus  have  failed,*  we  have  for  a  long  time  em- 

•  Efforts  to  do  so  were  made  by  Beck,  Kiproff  and  Brueninga.  A  pro- 
cedure which  serves  to  show  and  to  simultaneously  record  details  in  the  kind 
of  nystagmus  which  cannot  be  recognized  with  the  naked  eye,  is  the  so-called 
nystagmography   {Wojatschek,  Buys). 


FUNCTIOXAL  EXAMINATION  7 

ployed  an  empirical  division  of  nystagmus  into  three 
grades.  This  classification  is  based  upon  the  law  that  a 
nystagmus  is  increased  in  intensity  by  having  the  subject 
look  in  the  direction  of  the  quick  component  and  is  de- 
creased by  fixing  the  gaze  in  the  direction  of  the  slow  com- 
ponent. That  is  to  say,  if  we  allow  a  patient  with,  for  ex- 
ample, a  right  nystagmus,  to  look  to  the  right,  then  the 
nystagmus  becomes  more  pronounced  than  when  he  looks 
straight  ahead;  and  if  we  have  him  look  to  the  left,  the 
nystagmus  becomes  less  or  entirely  disappears.  Con- 
versely, we  may  conclude,  when  we  are  able  to  recognize  a 
nystagmus  to  the  right  only  when  it  is  accentuated  by  hav- 
ing the  patient  look  to  the  right,  that  this  is  a  very  mild 
nystagmus,  i.e.  of  the  first  degree.  If,  however,  there  ex- 
ists a  readily  noticeable  nystagmus  to  the  right  when  the 
patient  looks  directly  forwards,  then  this  must  be  stronger 
than  the  preceding,  for  we  do  not  need  to  reinforce  it  by 
having  the  subject  look  in  the  direction  of  the  quick  com- 
ponent in  order  to  make  it  visible.  This  constitutes  a 
nystagmus  of  the  second  degree.  This  grade  disappears 
when  the  subject  looks  to  the  left. 

Still  more  pronounced  must  be  a  nystagmus  to  the  right 
w^hich  is  still  apparent  even  when  the  subject  is  caused  to 
direct  his  eyes  to  the  left;  that  is,  in  the  direction  of  the 
slow  component,  in  which  case  we  are  opposing  the  nystag- 
mus. Such  a  marked  nystagmus  is  known  as  one  of  the 
third  grade. 

In  the  course  of  an  examination  with  our  stimuli  (caloric, 
or  rotation),  we  know  in  advance  the  direction  of  the 
nystagmus  we  are  to  expect,  and  so  can  at  once  recognize  it 
by  intensifying  it  by  having  the  patient  fix  his  eyes  in  the 
proper  direction.  On  the  contrary,  in  the  case  of  a  spon- 
taneous nystagmus,  we  know  nothing  in  advance  as  to  its 
direction,  and  so  we  are  obliged  to  test  the  patient  by  hav- 
ing him  look  alternately  to  the  right  and  left,  upwards  and 
downwards.  The  finger  employed  for  fixation  should  be 
held  about  one-half  meter  from  the  patient's  eyes,  and 


8  DISEASES  OF  THE  LABYRINTH 

should  be  moved  only  so  far  to  the  side  and  backwards  as 
to  be  comfortably  followed. 

Sometimes  there  exists  a  nystagmus  of  the  second  grade, 
which,  however,  cannot  be  observed  because  the  patient  in 
looking  straight  forwards  chances  to  fix  his  gaze  upon  a 
near  object,  which  act  is  sufficient  to  suppress  a  nystagmus 
of  moderate  grade.  For  such  cases,  we  employ,  according 
to  the  suggestion  of  Bar  any -Ah  el,  opaque  spectacles;*  or, 
following  Bruenings,  a  small  mirror  is  attached  by  a  head- 
band and  held  before  the  eyes;  this  causes  the  eyes  to  ac- 
commodate for  infinity  and  fixation  is  avoided. 

D.  PRODUCTION  OF  NYSTAGMUS  BY  PHYSIO- 
LOGICAL STIMULI 

We  are  able  to  produce  movements  of  the  lymph  by 
means  of  different  stimuli.    These  are : 

1.  Caloric. 

2.  Rotation,  or  turning. 

3.  Mechanical  violence  (fistula  test). 

These  are  the  stimuli  at  our  disposal  in  the  order  of  the 
intensity  with  which  they  work.  This  difference  in  their 
effect  has  been  deduced  from  the  observation  that,  in  patho- 
logical cases,  the  caloric  reaction  is  lost  in  cases  relatively 
more  slightly  affected  than  is  the  rotation  reaction;  and 
the  reaction  to  the  fistula  test  is  lost  only  in  the  most  se- 
verely altered  labyrinths. 

1.   Rotation,  or  Turning  Stimulus 

According  to  Ewald's  experiments,  for  the  details  of 
which  we  have  not  the  space,  we  must  assume  that  in  the 
horizontal  semicircular  canal  the  movement  of  the  endo- 
lymph  from  the  small  or  smooth  end  to  the  ampullated  end 
is  the  more  effective ;  and  such  movement  causes  a  nystag- 
mus to  the  same  side ;  whereas  the  movement  from  the  am- 

*  Bartels  uses  strong  convex  lenses  instead  of  opaque  spectacles,  accom- 
plishing the  same  result,  with  the  added  advantage  of  enabling  the  observer 
to  see  the  patient's  eyes  considerably  magnified.     (Editor.) 


F UXC TIOXA  L  EXAMIXA  TIOX 


pulla  toward  the  small  end  is  the  less  effective  and  produces 
a  nystagmus  to  the  opposite  side. 

Let  us  assume  that  we  rotate  ourself  in  the  horizontal 
plane;  i.e.  about  our  longitudinal  axis  to  the  right,*  then 
the  lymph  in  the  two  horizontal  canals,  by  virtue  of  its  in- 
ertia, moves  toward  the  left  ;t  that  is,  in  the  right  horizontal 
canal  there  results  a  current  from  the  small  end  toward  the 
ampulla. 

Rear 


Right 


Left 


In  the  left  horizontal  canal  the  current  moves  from  the 
ampulla,  toward  the  small  end  and  causes  a  nystagmus  to 
the  opi)osite  side,  which  is  also  to  the  right  side.  We  there- 
fore obtain  a  horizontal  nystagmus  to  the  right,  which  is 
stimulated  by  impulses  coming  from  the  horizontal  semi- 
circular canals  of  both  sides. 

The  same  deduction  holds  good  for  rotation  to  the  left. 

During  the  turning  in  the  horizontal  plane  no  apprecia- 
ble movement  of  the  lymph  takes  place  in  the  other  semi- 
circular canals,  for  they  occupy  a  position  perpendicular  to 
the  plane  of  rotation.* 

*  We  designate  turning  to  the  right  that  movement  which  corresponds  in 
direction  to  the  movement  of  the  hands  of  the  clock. 

tThis  naturally  is  the  case  only  in  the  beginning  of  the  rotation,  hut  the 
hairs  of  the  crista  ampullaris  remain  deviated  for  some  time,  until,  because 
of  their  elasticity,  they  return  to  the  position  of  rest.  For  the  sake  of 
simplicity  we  assume  that  it  is  not  the  bending  of  the  hairs,  but  the  move- 
ment of  the  lymph  which  causes  the  bending,  which  is  the  cause  of  the 
nystagmus. 

I  wish  here  to  state  that  the  first  portion  of  this  work  covering  the  physi- 
ology' has  been  written  particularly  in  response  to  the  wish  of  my  students, 
for  which  reason,  upon  didactic  grounds,  I  have  at  certain  points  simplified 
the  too  complicated  features  at  the  cost  of  scientific  exactness. 


10  DISEASES  OF  THE  LABYEINTH 

Since  in  each  canal  the  maximum  movement  of  the  lymph 
takes  place  when  the  canal  lies  in  the  plane  of  the  turning, 
and  since  we  make  our  investigation  by  means  of  the  turn- 
ing chair  (whose  axis  is  vertical  to  the  floor)  and  conse- 
quently the  plane  of  movement  is  always  horizontal,  it  fol- 
lows that  in  testing  the  other  semicircular  canals,  these 
should  be  placed  in  approximately  the  horizontal  position. 
Accordingly,  in  testing  the  frontal  semicircular  canal,  the 
head  should  be  held  bent  forward  or  to  the  rear,  and  in  test- 
ing the  sagittal  canals,  the  head  should  be  inclined  toward 
the  right  or  left  shoulder. 


Eear 


Right 


If  we  turn  ourself  to  the  right,  for  instance,  with  the 
head  bent  forward,  then,  in  the  right  frontal  canal,  the 
lymph  current  flows  from  the  ampulla  toward  the  smooth 
end,  and  in  the  left  frontal  semicircular  canal,  from  the 
smooth  end  toward  the  ampulla. 

According  to  Etvald,  we  must  assume  that  in  the  case 
of  both  vertical  semicircular  canals  (the  frontal  and  sagit- 
tal), contrary  to  what  occurs  in  the  horizontal  canals,  the 
movement  from  the  ampulla  to  the  smooth  end  causes 
nystagmus, to  the  same  side,  and  from  the  smooth  end  (or 
small  end)  toward  the  ampulla,  a  nystagmus  to  the  opposite 
side. 

•  For  the  sake  of  simplicity  we  make  the  assumption,  which  is  not  scien- 
tifically true,  that  the  three  semicircular  canals  are  placed  in  the  three 
planes  of  space. 


FUNCTIONAL  EXAMINATION  11 

Thus  we  now  also  obtain,  analogously  to  the  rotation  with 
head  erect,  a  nystagmus  originating  in  both  sides  and  di- 
rected toward  the  right. 

The  movement  in  the  right  frontal  semicircular  canal  is 
the  more  effective  and  gives  a  strong  stimulus  for  nystag- 
mus to  the  right ;  at  the  same  time,  the  less  effective  move- 
ment of  lymph  in  the  left  frontal  semicircular  canal  pro- 
duces a  weaker  impulse,  likewise  for  nystagmus  to  the  right. 
In  this  case  we  again  obtain  a  nystagmus  to  the  right,  hav- 
ing its  origin  in  both  frontal  semicircular  canals,  but  the 
greater  stimulus  coming  from  the  right. 

If  now  we  rotate  to  the  right  with  the  head  inclined  back- 
ward, there     results  in  the  right  frontal  canal  a  current 

Rear  » 


Right     A  I  I  I  \   \\     I^eft 


from  the  smooth  end  toward  the  ampulla,  that  is,  a  less  ef- 
fective impulse,  exciting  a  weak  impulse  for  nystagmus  to 
the  opposite  side,  i.e.  a  nystagmus  to  the  left.  At  the  same 
time  there  occurs  in  the  left  frontal  semicircular  canal  a 
lymph  current  from  the  ampulla  toward  the  smooth  end, 
a  more  effective  movement,  producing  a  strong  impulse  for 
nystagmus  to  the  same  side,  which  is  likewise  the  left  side. 
AVe  thus  obtain  through  rotation  to  the  left,  with  the  head 
inclined  backward,  nystagmus  to  the  left.  In  like  manner 
we  may  deduce  the  fact  that  for  turning  to  the  left,  with 
head  inclined  forward,  we  have  nystagmus  to  the  left,  and 
with  head  inclined  backward,  we  get  nystagmus  to  the  right. 
Nystagmus  produced  by  turning  with  the  head  inclined 
backward  or  forward  is  always  a  rotatory  nystagmus,  in- 


12 


DISEASES  OF  THE  LABYRINTH 


asmiieh  as  it  is  produced  by  the  frontal  semicircular 
canal. 

The  sagittal  semicircular  canal  is  brought  into  the  hori- 
zontal phine  of  rotation  by  inclining  the  head  toward  the 
right  or  left  shoulder. 

Here  we  must  i)oint  out  one  difference  from  the  preced- 
ing illustrations,  i.e.  the  two  semicircular  canals  in  this  po- 
sition, during  rotation,  lie  not  like  the  two  horizontal  and 
frontal  canals,  which  are  on  opposite  sides  of  the  axis  of 
turning,  but  they  are  both  upon  the  same  side,  and,  in  con- 
sequence, in  both  canals  there  follows  a  movement  of  lymph 
in  the  same  direction. 


Left 


Front 


Right 


If  we  are  turned,  for  example,  to  the  right,  with  the  head 
inclined  to  the  right  side,  there  occurs  in  both  canals  a  cur- 
rent from  the  ampulla  toward  the  smooth  end,  the  more 
effective  movement,  which  should  call  forth  a  nystagmus 
to  the  same  side;  but  since  the  sagittal  canal  can  produce 
a  nystagmus  only  in  the  sagittal  plane,  that  is,  upward  or 
downward,  there  occurs  a  vertical  nystagmus,  and,  corre- 
sponding to  the  more  effective  movement,  the  nystagmus  is 
directed  upward. 


FUNCTIONAL  EXAMIXA  Tl ON 


13 


Again,  if  we  are  turned,  for  example,  to  the  right,  with 
head  inclined  to  the  left,  there  follows  in  both  vertical  semi- 
circular canals  a  lymph  current  from  the  smooth  end  to- 
ward the  ampulla;  that  is,  the  less  effective  movement, 
which  calls  forth  a  nystagmus  in  the  opposite  direction  from 
that  called  forth  by  the  more  effective  movement,  conse- 
quently a  nystagmus  directed  downward. 


Left 


Right 


Everything  which  has  thus  far  been  stated  is  valid  only 
for  nystagmus  during  the  act  of  rotation.  If  we  suddenly 
arrest  the  turning,  there  follows  a  lymph  current  in  the 
direction  opposite  to  that  which  existed  during  turning,* 
with  the  result  that  we  get  also  a  nystagmus  in  the  opposite 
direction.    This  we  call  the  after-nystagmus. 

If  we  wish  to  formulate  rules  for  the  after-nystagmus, 
then  it  is  only  necessary  to  reverse  the  rules  above  given. 
P^r  example,  let  us  consider  the  case  of  turning  to  the  right 
with  head  erect. 


*  We  take  this  for  granted  for  the  sake  of  simplicity.  In  reality  the 
lymph  continues  to  move  in  the  direction  of  the  rotation  in  consequence  of 
its  inertia ;  thereby,  however,  the  cupula  is  displaced  in  the  opposite  direction 
from  that  which   it  occupied  during  the   turning. 


14  DISEASES  OF  THE  LABYEIMU 

During  the  turning,  in  the  riglit  horizontal  semicircular 
canal  we  have  movement  of  lymph  from  the  small  end  to- 
ward the  ampulla,  hence  the  more  effective  movement,  call- 
ing forth  horizontal  nystagmus  to  the  right;  simulta- 
neously, movement  of  lymph  in  the  left  horizontal  canal 
from  the  ampulla  toward  the  smooth  end,  which  is  less  ef- 
fective, giving  nystagmus  to  the  opposite  side  (also  to  the 
right),  therefore  producing  nystagmus  to  the  right. 

Rear 


Right  (      (^  ^ ^  . ^  )       )  Left 

Front 
Fig.  10 
The    smooth    arrow    indicates    the    direction  of  the  lymph  current  upon 
stopping  the  turning. 

If  the  turning  be  suddenly  arrested,  there  follows  a  move- 
ment of  IjTnph  in  the  right  horizontal  canal  from  the  am- 
pulla (smooth  arrow)  toward  the  smooth  end.  This  is 
the  less  effective  movement  and  calls  forth  a  nystagmus  to 
the  opposite  or  left  side.  Simultaneously,  there  occurs  in 
the  left  semicircular  horizontal  canal  a  movement  toward 
the  ampulla,  which  is  the  more  effective  impulse,  a  nystag- 
mus to  the  same  side,  which  is  the  left,  and  there  results  a 
horizontal  nystagmus  to  the  left. 

In  the  same  manner  we  can  deduce  the  results  for  all  the 
other  semicircular  canals.    For  convenience,  we  give  here 
the  results  of  such  deductions: 
Rotation  to   right  and   arresting  motion,   head  upright: 

Horizontal  nystagmus  to  the  left. 
Rotation    to    left    and    arresting   motion,    head    upright: 

Horizontal  nystagmus  to  the  riglit. 
Rotation  to  right  and  arresting  motion,  head  bent  forward : 

Rotatory  nystagmus  to  the  left. 


FUNCTIONAL  EXAMINATION  15 

Rotation  to  left  and  arresting  motion,  head  bent  forward: 

Rotatory  nystagmus  to  the  right. 
Rotation  to  right  and  arresting  motion,  head  bent  back- 
ward :  Rotatory  nystagmus  to  the  right. 
Rotation  to  left  and  arresting  motion,   head  bent  back- 
ward :  Rotatory  nystagmus  to  the  left. 
Rotation  to  right  and  arresting  motion,  head  inclined  to- 
ward right  shoulder:    Nystagmus  downward. 
Rotation  to  right  and  arresting  motion,  head  inclined  to- 
ward left  shoulder:  Nystagmus  upward. 
Rotation  to  left  and  arresting  motion,  head  inclined  toward 

left  shoulder :  NystagTQUs  downward. 
Rotation  to  left  and  arresting  motion,  head  inclined  toward 
right  shoulder :  Nystagmus  upward. 
Very  naturally  the  nystagmus  which  we  can  observ^e  after 
rotation  is  more  practically  useful  than  nystagmus  during 
turning.  Therefore,  in  practice,  we  observe  only  the  after- 
nystagmus,  and  here  we  greatly  simplify  the  whole  matter. 
"We  are  interested  in  knowing  whether  or  not  a  labyrinth 
is  destroyed.  For  this  purpose  it  is  quite  enough  to  de- 
termine the  nystagmus  of  one  semicircular  canal.  For  the 
patients,  the  least  unpleasant  test  is  that  with  the  head 
erect,  for  reaction  symptoms  (vertigo,  nausea,  etc.)  are  the 
least  pronounced.  Accordingly  we  regularly  make  only 
this  test.  Bdrdny  proved  that  the  most  reliable  test  is  at- 
tained by  ten  revolutions;  and  that  then  the  duration  of 
the  after-nystagmus  is  twenty  to  forty  seconds  in  the  nor- 
mal subject. 

Accordingly  we  make  the  practical  examination  as  fol- 
lows :  The  patient  is  placed  upon  the  turning  chair,*  with 
head  erect  and  wearing  opaque  spectacles.  He  is  turned 
ten  times  to  the  right,  then,  after  suddenly  arresting  the 
turning,  the  duration  of  the  nystagmus  is  measured  accu- 

*In  the  absence  of  a  specially  constructed  chair  for  the  rotation  test,  one 
may  be  improvised  by  utilizing  the  ordinary  revolving  office  desk  chair  with 
arms,  adjusting  it  to  the  maximum  height  and  tightening  the  spring  of  the 
tilting  mechanism.  A  board  4"  x  1"  x  30"  placed  between  the  patient's 
back  and  the  back  of  the  chair  will  aid  in  supporting  the  head. —  (Editor.) 


16 


DISEASES  OF  THE  LABYRINTH 


rately  with  a  stop-watcli.  Next,  the  patient  is  turned  ten 
times  to  the  left,  and  again  the  duration  of  the  after- 
nystagmus  noted.  The  normal  individual  gives  the  follow- 
ing result: 


Fig.  10a 
Sketch  of  a  Special  Revolving  Chair. 

10    revolutions    to    the    right    produce    horizontal    after- 
nystagmus  to  left,  duration  20"  —  40". 
10    revolutions    to    the    left    produce    horizontal    after- 
nystagmus  to  right,  duration  20"  —  40". 
If,  on  the  contrary,  one  labyrinth  is  destroyed,  for  in- 
stance, the  right,  then  we  may  get  the  following  result. 
10  revolutions  to  the  right  give  an  after-nystagmus  to  the 

left,  duration  20"  — 40". 

10  revolutions  to  the  left  give  an  after-nystagmus  to  the 

right,  duration  5"  — 15". 

This  result  speaks  for  a  probable  destruction  of  the  right 

labyrinth.    No  nystagmus  at  all  to  the  right,  after  turning 

to  the  left,  must  not  be  expected  even  in  the  case  of  com- 


FUNCTIONAL  EXAMINATION  17 

plete  destruction  of  the  right  hibyrinth,  for  we  know  that 
the  left  labyrinth,  through  rotation  to  the  left  and  stopping, 
produces  some  nystagmus  to  the  right  in  consequence  of  the 
less  effective  lymph  current  in  the  left  horizontal  semi- 
circular canal.  Further,  this  fact  is  often  stillmore  signifi- 
cant; and  the  differences  are  also  still  less  noticeable  in 
cases  of  total  destruction  of  a  labyrinth;  positive  conclu- 
sions, therefore,  cannot  then  be  drawn,  especially  because 
it  has  been  proved  by  Bciidny  that  even  in  normal  subjects 
great  differences  may  exist  in  the  duration  of  nystagmus 
from  the  two  sides. 

Furthermore,  it  is  possible  that  in  a  case  with  total  de- 
struction of  one  labyrinth  the  nystagnms  after  turning  to 
the  right  and  left  is  quite  equal,  when  the  so-called  com- 
pensation has  become  established.  I  have  pointed  out  that  in 
cases  of  long  standing  destruction  of  one  labyrinth  (ossifi- 
cation or  sequestration)  the  nystagmus  after  turning  may 
be  alike  for  both  sides.  More  will  be  said  about  this  phe- 
nomenon later. 

From  the  degree  of  the  difference,  when  the  same  is  not 
the  noticeable  difference  which  is  characteristic  for  a  total 
destruction  of  the  labyrinth,  it  is  impossible  to  draw  con- 
clusions as  to  the  greater  or  lesser  irritability  of  the  patho- 
logically inflamed  labyrinth,  even  if  we  have  found  in  cir- 
cumscribed and  diffuse  labyrinthitis  in  general  diminished 
values  for  the  duration  of  the  after-nystagmus.  We  can- 
not properly  speak  of  a  hyper-irritability  toward  physiolog- 
ical stimuli  in  the  case  of  an  inflamed  labyrinth,  as  I  have 
proved  for  the  caloric*  stimulus. 

I  wish  to  call  attention  to  certain  sources  of  error  in  the 
rotation  test.f  First,  the  duration  of  the  after-nystagmus 
may  be  difficult  to  determine  when  there  exists  a  sponta- 
neous nystagmus.  Then  we  use  the  fixation  apparatus  of 
Bdrdny. 

•Deutsche    Otol.   Ges.,    May,    1909,  Basel. 

tA   case  of  complete  absence  of  rotation   nystatins  without   explainable 
cause  was  described  by  Leidler   (Z.  f.  O.  Bd.  56,  H.  4). 


18 


DISEASES  OF  THE  LABYRINTH 


The  small  rod  with  the  fixation  point  is  so  adjusted  as  to 
cause  the  nystagmus  to  disappear.  After  rotation,  the  sub- 
ject is  again  asked  to  look  at  the  fixation  point,  when  a 
nystagmus  is  observed  which  did  not  exist  before. 


Further,  strabismus  may  be  a  source  of  error  in  our  ob- 
servations. I  have  found  that  the  squinting  eye  during  and 
after  turning  may  often  be  forcibly  and  rigidly  turned  to- 
ward the  inner  or  outer  canthus,  and  we  then  get  the  im- 
pression that  only  the  non-squinting  eye  shows  nystagmus. 

2.    Caloric  Irritation 

Bdrdny  discovered  that  syringing  an  ear  with  cold  water 
produces  a  nystagmus  to  the  opposite  side  and  syringing 
with  hot  water  results  in  a  nystagmus  to  the  same  (its  own) 
side.  This  is  explained  by  the  physical  fact  that  contact 
of  cold  water  with  the  labyrinth  wall  produces  a  lymph  cur- 
rent directed  downward,  while  contact  with  warm  water 
causes  a  current  upward. 

If  we  consider  this  explanation  in  the  light  of  Ewald's 
laws,  it  is  easy  to  deduce  the  kind  of  nystagmus  produced. 
In  bringing  heat  or  cold  to  bear  upon  the  labyrinth  wall, 
we  have  to  consider  only  those  parts  lying  next  the  outer 
wall ;  i.e.  the  outer  bend  and  the  ampulla  of  the  vertical  and 
horizontal  semicircular  canals. 


FUNCTIONAL  EXAMINATION  19 

If  we  inject  cold  water  against  the  labyrinth  wall  there 
follows  a  current  from  above  downward  (Fig.  12,  smooth 
arrow),  that  is,  in  the  frontal  semicircular  canal,  a  move- 
ment from  the  smooth  end  to  the  ampulla,  the  less  effective 
movement,  which  causes  nystagmus  to  the  opposite  side; 
and  since  it  is  a  frontal  semicircular  canal,  the  nystagmus 
is  rotatory. 


Fig.  12 
Right  frontal   and  horizontal  semicircular  canals. 

In  the  horizontal  semicircular  canal  there  results  a 
movement  w^hich  is  from  the  ampulla  to  the  smooth  end 
(Fig.  12,  smooth  arrow),  that  is,  for  the  horizontal  semi- 
circular canal,  the  less  effective  movement,  which  also 
causes  a  nystagmus  to  the  opposite  side  (also  to  the  left). 
Accordingly  there  results  a  rotatory  and  horizontal  nystag- 
mus to  the  left.  Naturally  the  rotatory  nystagmus  is 
stronger  than  the  horizontal,  since  the  hydrostatic  fall  is 
greater,  and  therefore  the  current  is  decidedly  greater. 
The  horizontal  nystagmus  is  only  very  limited;  it  would 
not  be  present  at  all  were  the  horizontal  canal  absolutely 
hoi'izontal  in  its  position,  for  then  there  would  be  no  cur- 
rent produced.  If  we  syringe  hot  water  against  the  laby- 
rinth wall,  for  example,  of  the  right  ear,  there  follows  a 
current  from  below  upward  (Fig.  12,  feathered  arrow), 
that  is,  in  the  frontal  semicircular  canal,  a  current  from 
the  ampulla  toward  the  smooth  end,  i.e.  the  more  effective 
movement,  which  produces  a  movement  to  the  same  side. 


20  DISEASES  OF  THE  LABYRIXTII 

wliich,  since  it  originates  in  the  frontal  canal,  is  rotatory. 
In  the  horizontal  semicircular  canal,  there  results  a  move- 
ment of  the  lymph  from  the  smooth  end  toward  the  am- 
pulla (Fig.  12,  feathered  arrow),  which,  for  the  horizontal 
semicircular  canal,  is  the  more  effective  one,  calling  forth 
a  nystagmus  to  the  same  side.  Therefore,  we  get  a  hori- 
zontal nystagmus  to  the  same  side.  The  rotatory  is,  as 
above  noted,  stronger  than  the  horizontal. 

Let  us  imagine  now  that  the  canals  occupy  a  reversed 
position ;  that  is,  the  ampulla  above ;  then  we  should  obtain 
a  reversed  nystagmus;  that  is,  with  cold  water  we  would 
get  a  rotatory  and  a  horizontal  nystagmus  to  the  same  side, 
and  with  hot  water,  to  the  opposite  side.  This,  as  Bdrdny 
has  proved,  is,  in  fact,  the  case  when  the  head  is  inclined 
forward  180°. 

If  the  head  is  inclined  toward  the  left  shoulder  and  cold 
water  is  injected  into  the  right  ear,  we  obtain  a  horizontal 
nystagmus  to  the  right,  for  now  the  horizontal  canal  occu- 
pies a  position  such  that  its  smooth  end  is  higher  than  the 
ampulla,  and  the  current  flows  toward  the  ampulla,  causing 
the  more  effective  movement,  which  produces  a  horizontal 
nystagmus  to  the  same  side. 
By  inclination  of  the  head  we  get  results  as  follows : 

Cold  water  into  right  ear,  head  inclined  toward  left  =  hori- 
zontal nystagmus  to  right. 

Cold  water  into  left  ear,  head  inclined  to  right  =  horizontal 
nystagmus  to  left. 

Hot  water  into  right  ear,  head  inclined  to  left  —  horizontal 
nystagmus  to  left. 

Hot  water  into  left  ear,  head  inclined  to  right  ==  horizontal 
nystagmus  to  right. 

According  to  Hofer  (Verb.  d.  D.  otol.  Ges.,  Frankfurt, 
1911),  in  most  cases  we  get  the  same  results  if  we  carry 
out  the  syringing  with  head  erect,  but  immediately  there- 
after have  the  head  inclined  in  the  various  positions. 

This  must  be  kept  in  mind  in  making  the  caloric  test,  and 


FUNCTIONAL  EXAMINATION 


21 


therefore  during  the  test  we  must  see  to  it  that  the  head 
is  held  strictly  in  the  upright  position. 

In  making  the  caloric  test  we  use  cold  water  at  a  tem- 
perature of  20°  —  30°  C.  (68°  —86°  F.).  Water  which  is 
too  cold  (below  20°  C.  or  68°  F.)  is  not  desirable,  for  the 
accompanying  symptoms  (vertigo,  nausea  and  emesis) 
ordinarily  are  more  severe  the  stronger  the  nystagmus. 
The  nystagmus  is  more  intense  the  colder  the  water  and 
the  longer  it  is  injected.  Naturally,  in  those  cases  in  which 
water  of  20°  does  not  yield  a  definite  reaction,  we  would 
employ  colder  water  without  fear  of  severe  associated 
symptoms. 


Fig.  13 


Similarly,  in  the  presence  of  acute  otitis,  in  consequence 
of  the  presence  of  secretion  and  of  the  increased  blood  sup- 
ply of  the  tympanic  membrane  and  the  mucous  membrane 
of  the  tympanic  cavity,  the  action  of  the  water  is  dimin- 
ished. This  fact  is  supported  by  the  experiment  of  Beck, 
who,  by  applications  of  adrenalin,  was  able  to  obtain  the 


22 


DISEASES  OF  THE  LABYRINTH 


caloric  reaction  in  half  the  time  required  under  ordinary 
conditions. 

The  time  required  for  the  caloric  reaction  to  appear  de- 
pends upon  the  accessibility  of  the  labyrinth  wall  to  the 
fluid  employed.  According  to  Kallmann  (Passow's  Beitrage 
Bd.  V,  H.  2),  the  caloric  reaction  appears  in  normal  indi- 
viduals in  thirty-six  seconds ;  in  the  presence  of  chronic  sup- 
puration, in  forty  seconds ;  while  in  cases  of  total  destruc- 
tion of  the  drum,  and  after  the  radical  mastoid  operation,  in 
ten  seconds. 


Fig.  14  Fig.  15 

The  electric  heating  element  a  is  inserted  into  the  hose  and  covered  with 
asbestos.  Turning  the  switch  over  one  contact  gives  a  cool  current  of  air, 
and  turning  it  to  the  second  point  puts  the  heating  element  into  the  circuit, 
and  a  current  of  hot  air  is  produced.  The  tips  d  and  e  make  it  possible 
to  easily  introduce  the  air  into  the  meatus. 


Granulations,  cholesteatomatous  masses,  etc.,  lying  be- 
fore the  labyrinth  wall  may  retard  the  action  of  the  caloric 
test.  In  general,  we  consider  it  a  proof  that  the  power  to 
respond  is  lost,  when,  after  the  injection  of  three  liters  of 
water  at  16°  — 18°  C.  (60.8°  — 64.4°  F.),  there  is  no 
reaction. 

The  test  is  best  carried  out  by'means  of  the  irrigating  ap- 
paratus I  have  devised  (Fig.  13). 


FUNCTIOXAL  EXAMINATION  23 

The  water  is  caught  iu  a  rubber  pocket  having  a  drain 
pipe. 

In  some  cases  it  is  wise,  even  with  chronic  purulent  dis- 
charge or  cholesteatomatous  masses,  to  avoid  irrigation,  be- 
cause of  the  risk  of  too  severe  a  reaction  or  of  spreading 
an  infection.  In  such  cases  the  reaction  may  be  brought 
about  by  the  insuflBation  of  a  spray  of  air,  cooled  by  pass- 
ing the  current  through  ether  (Fig.  14). 

Other  devices  for  introducing  cold  air  have  been  de- 
scribed by  Block  and  Aspissoff. 

Most  recently  I  have  so  modified  the  Foen  air  apparatus 
that  it  appears  to  be  especially  well  adapted  for  the  caloric 
test  with  cold  and  hot  air. 

3.    Mechanical  Irritation 

In  the  fistula  test  we  must  naturally  have  for  a  reaction 
a  fistula  into  the  labyrinth.  "We  must  assume  that  all  cases 
which  give  a  positive  reaction  to  the  rotation  and  caloric 
tests  would  give  the  fistula  reaction  were  an  opening  artifi- 
cially made  into  the  labyrinth. 

The  fistula  test  is  carried  out  with  a  small,  elastic,  thick- 
walled  rubber  bag  or  bulb  (ordinarily  a  small  Politzer  bag, 
without  valve),  to  which  is  attached  a  tube  and  an  olive  tip. 

The  tip  is  inserted  into  the  canal  of  the  ear  under  ex- 
amination in  such  a  manner  as  to  prevent  leakage  of  air, 
and  the  result  of  compression  and  aspiration  of  the  air  is 
observed  as  it  affects  the  eyes. 

In  those  cases  in  which  there  is  a  very  patent  Eusta- 
chian tube,  the  air  escapes  so  rapidly  that  the  compression 
is  not  great  enough  to  elicit  the  fistula  symptom.  In  such 
cases  I  have  suggested  that  at  the  very  moment  of  com- 
pression the  patient  perform  inflation  by  the  Valsalva 
method  to  counteract  the  loss  by  the  Eustachian  tubes,  when 
the  fistula  reaction  may  be  made  to  appear. 

In  cases  in  which  there  is  a  postauricular  fistula  or  large 
operative  wound,  we  employ,  as  suggested  by  Bdrdny,  in- 
stead of  the  olive  tip,  a  bell  (such  as  is  used  for  cupping 


24  DISEASES  OF  THE  LABYRINTH 

or  for  hyperaemia  treatments),  covering  the  entire  region 
of  the  ear. 

The  effect  of  the  compression  is,  in  tj'pical  cases,  a  nys- 
tagmus toward  the  affected  side,  or  a  slow  movement  of 
the  eyes  toward  the  non-affected  side.  Aspiration  has  the 
opposite  effect;  i.e.  a  nystagmus  toward  the  normal  side, 
or  a  slow  eye  movement  toward  the  diseased  side. 

The  explanation  as  to  why  we  call  this  result  the  typical 
reaction  and  designate  any  other  as  atypical  rests  entirely 
upon  an  empirical  basis;  for,  from  experience,  we  know 
that  the  great  majority  of  labyrinth  fistulae  behave  in  thi? 
way.  By  reversing  our  conclusion  we  are  able  to  explain 
the  phenomenon.  Assuming  that  there  is  a  fistula  in  the 
horizontal  semicircular  canal,  then  we  must  conclude  that 
compression,  if  it  provokes  a  nystagmus  to  the  same  side, 
sets  up  a  lymph  current  from  the  smooth  end  to  the  am- 
pulla, and  aspiration  must  produce  the  opposite  effect. 

E.  RELATIVE  VALUE  OF  THE  STIMULI 
A  few  words  concerning  the  relative  quantitative 
strength  of  the  stimuli  employed  in  the  above  tests.  I 
have*  in  the  light  of  Fechner's  law,  divided  the  stimuli  into 
adequate  and  inadequate,  classifying  those  which  are  ef 
fective  by  virtue  of  producing  lymph  currents,  as  "ade- 
quate," whereas  those  which  work  directly  upon  the  nerve, 
as  the  galvanic  stimulus,  as  "  inadequate,  "f 

As  a  result  of  our  experience  with  labyrinthitis,  we  must 
arrange  the  stimuli  employed  according  to  their  strength 
of  action  in  the  following  order: 
Calorie  stimulus, 

•  Concerning  the  DifTercntial  Diagnosis  of  Diseases  of  the  Vestibular 
Apparatus,  the  Vestibuh\r  Nerve  and  its  Central  Tracts,  Verh.  d.  Deutseh. 
otol.  Gessellsch.,  May,    1909,   Basel. 

tRecently  Brueninpa  (Verh.  d.  Deutseh.  otol.  Gesell..  Dresden,  1910) 
attempted  to  prove  that  the  galvanic  nystagmus  also  originates  from  lymph 
currents,  the  result  of  cataphoresis.  According  to  Ifrueniiifis'  view,  tlien,  we 
should  also  classify  the  galvanic  stimulus  as  "adequate."  This  is  not  the 
place  to  go  into  the  details  of  this  problem,  especially  since  thus  far  the 
galvanic  test  has  proved  of  little  clinical  value  in  studying  labyrintliine 
inflammations. 


FUNCTIONAL  EXAMINATION  25 

Turning  or  rotation  stimulus, 

Mechanical  stimulus  (fistula  test), 
the  caloric  being  the  weakest,  the  mechanical  the  strongest. 
This  conception  we  must  hold  therefore,  because  in  cases 
of  serous  labyrinthitis  only  the  effectiveness  of  the  caloric 
stimulus  is  first  lost,  more  seldom  the  effectiveness  of  the 
rotation  stimulus.  Finally,  cases  in  which  the  caloric,  turn- 
ing and  fistula  tests  all  excite  no  reaction  are  either  cases 
characterized  by  a  sudden  total  obliteration  of  the  labyrinth 
function,  or  cases  of  old  labyrinth  destruction. 

In  s])ite  of  this  difference  in  the  quantitative  value  of 
the  different  stimuli,  we  must  still  conceive  of  them  as  of 
the  same  nature;  for  I  was  able  to  show  by  the  following 
experiment  that  the  nystagmus  produced  by  one  of  these 
stimuli  can  be  completely  arrested  by  another.  In  a  pa- 
tient with  a  readily  demonstrable  fistula  symptom  on  the 
right  side,  by  syringing  with  cold  water,  I  produced  a  ro- 
tatory nystagmus  to  the  right  side.  In  the  midst  of  this 
marked  rotatory  nystagmus  I  was  able,  by  compression  of 
the  air  in  the  meatus,  that  is,  by  a  stimulus  for  nystagmus 
to  the  left  (this  compression  being  of  a  given  strength),  to 
immediately  arrest  the  rotatory  nj^stagmus.  The  same  phe- 
nomenon resulted  also  when,  by  turning  to  the  left  with  the 
head  bent  forward  and  with  an  arrest  of  the  motion,  a  ro- 
tatory nystagmus  to  the  right  was  produced,  and  the  com- 
pression was  made.  The  similarity  between  the  caloric  and 
turning  stimuli  could  not  be  demonstrated  because  the  turn- 
ing and  caloric  tests  cannot  be  made  to  act  similarly  upon 
the  same  semicircular  canal.* 

F.   DISTURBANCES  OF  EQUILIBRIUM 

The  disturbances  of  equilibrium  produced  by  the  laby- 
rinth are  dependent  upon  the  nystagmus  (by  way  of  dis- 
tinction from  others  of  central  or  hysterical  origin)  and 
follow  the  direction  of  the  slow  component ;  that  is,  if  there 

*  Concprning   the    details    of   iirocedure   and    results   of   this   experiment    I 
Avill  report  later. 


26  DISEASES  OF  THE  LABYBINTE 

exists  a  rotatory  nystagmus  to  the  left,  then  the  body  has 
the  tendency  to  fall  toward  the  right.  The  explanation  for 
this  phenomenon  we  might  perhaps  seek  in  this:  that  the 
apparent  motion  of  external  objects  follows  in  the  direc- 
tion of  the  quick  component  of  the  nystagmus,  that  is,  the 
subject  believes  himself,  with  relation  to  space,  to  be  moved 
to  the  left  and  away  (from  the  object).  The  reaction  to  this 
apparent  movement  is  an  opposed  movement  of  the  body; 
that  is,  a  movement  to  the  right,  in  the  frontal  plane,  a 
movement  which  causes  the  body,  which  is  in  reality  at 
rest,  to  be  toppled  toward  the  right. 

Rotatory  nystagmus  toward  the  right,  therefore,  pro- 
duces disturbances  of  equilibrium,  with  the  tendency  to  fall 
toward  the  left;  and  rotatory  nystagmus  toward  the  left 
calls  forth  equilibrium  disturbances  with  a  tendency  to  fall 
toward  the  right. 

The  direction  of  the  fall  must  immediately  change  itself 
with  an  alteration  of  the  position  of  the  head.  For  exam- 
ple, if,  with  an  existing  rotatory  nystagmus  toward  the  left, 
the  head  be  turned  through  90°  to  the  left,  the  tendency  is 
to  fall  forward.  Relative  to  the  body  axis,  the  nystagmus 
.now  is  to  the  rear,  that  is,  the  slower  component  is  turned 
forward. 

If  we  turn  the  head,  90°  to  the  right,  with  a  nystagmus 
to  the  left,  then  it  follows  that  the  falling  is  toward  the  rear, 
for  now,  with  regard  to  the  body  axis,  the  nystagmus  is  for- 
ward, and  the  slow  component  is  directed  backward. 

In  a  simple  horizontal  nystagmus  there  follows  only  an 
apparent  movement  of  space  and  its  objects  in  the  direc- 
tion of  the  nystagmus;  there  is  no  tendency  to  falling,  for 
there  is  only  a  movement  in  the  horizontal  plane. 

The  dependence  of  the  direction  of  the  falling  upon  the 
nystagmus  is  to  such  a  degree  typical  that,  when  the  di- 
rection of  the  falling  does  not  correspond  to  the  slow  com- 
ponent of  the  nystagmus,  then  we  must  assume  that  there 
is  a  non-labyrinthine  cause  (of  central  origin,  hysteria). 

The    disturbances    of   equilibrium    do    not    have    much 


FUNCTIOXAL  EXAMINATION  27 

significance  in  the  inflammatory  and  purulent  diseases  of 
the  labyrinth.  In  circumscribed  labyrinthitis  there  is  usu- 
ally an  indefinite  swaying,  corresponding  to  the  limited 
nystagmus  which  is  often  directed  to  both  sides  or  is 
alternating.* 

In  diffuse  serous  and  in  diffuse  purulent  manifest  laby- 
rinthitis, the  tendency  to  fall  toward  the  diseased  side  is 
very  pronounced,  but  the  patients  are  usually  immediately 
confined  to  bed,  so  that  the  observation  of  this  phenome- 
non at  once  becomes  difficult.  On  the  other  hand,  however, 
there  is  also  another  manifestation,  which  does  not  cause 


Fig.   15«.    Laermapparat    (see  page   2) 

the  patient  any  particular  unpleasantness  and  which  is 
easily  observed.  This  is  the  forced  position  taken  by  the 
patient  for  his  comfort.  This  corresponds  to  the  quick  com- 
ponent of  the  nystagmus;  for  example,  a  patient  with  a 
right  diffuse  manifest  labyrinthitis  lies  by  preference  upon 
his  left  side.  This  is  manifestly  to  be  explained  by  the  fact 
that  in  this  position  he  reduces  his  field  of  vision,  and 
thereby  lessens  the  extent  of  the  apparent  movements. 
Conscious  of  his  position,  he  feels  no  need  of  a  correcting 
movement,  but  he  has  only  the  unpleasant  sensation  of  the 
diminished  apparent  movement. 

•  We  cannot  consider  here  the  complicated  experiment  of  von  Stein. 


CHAPTER  II 

CIRCUMSCRIBED  DIFFUSE  SEROUS  SECONDARY 
AND  DIFFUSE  PURULENT  LABYRINTHITIS 

Inflammations  of  the  labyrinth  occurring'  after  chronic 
middle  ear  suppurations  we  divide  into  the  following 
grades  :* 

1.  Circumscribed  labyrinthitis. 

2.  Diffuse  serous  secondary  labyrinthitis.! 

3.  Diffuse  purulent  labyrinthitis. 

For  purposes  of  diagnosis  and  treatment,  we  consider 
these  grades  of  one  and  the  same  process  as  separate  clin- 
ical pictures.  Each  of  these  three  forms  may  be  manifest 
or  latent.  The  stage  of  being  manifest  or  latent  expresses 
itself  in  the  presence  or  absence  of  symptoms  which,  in 
brief,  we  designate  as  labyrinth  symptoms.  By  the  term 
labyrinth  symptoms  we  understand,  besides  diminution  of 
the  hearing,  also  tinnitus,  as  a  symptom  on  the  part  of  the 
cochlear  apparatus;  and  nystagmus,  vertigo,  vomiting  and 
disturbances  of  equilibrium  as  symptoms  on  the  part  of  the 
vestibular  apparatus. 

A.   PATHOLOGY 

In  the  circumscribed  labyrinthitis,  we  are  dealing  either 
with  only  a  defect  in  the  wall,  or  with  an  inflammation  lim- 
ited to  the  inmiediate  vicinity  of  this  defect,  be  it  of  a 
serous,  sero-fibrinous  or  purulent  nature.  (We  are  well 
aware  that  the  defect  in  the  labyrinth  wall,  strictly  speak- 
ing, does  not  always  mean  a  labyrinthitis,  but  we  are  as 

*  After  acute  otitis  media  these  forms  of  labyrinthitis  occur  only  excep- 
tionally; on  the  other  hanil.  another  form  of  labyrinthitis,  an  inflammation 
extendin;/  directly  throufih  the  labyrinth  wall,  which  we  designate  by  the 
name  "diffuse  serous  induced  labyrinthitis,"  we  will  later  consider  in  detail. 

fWe  understand  by  serous  also  sero-fibrinous. 

28 


PATHOLOGY  29 

yet  unable  to  clinically  differentiate  such  a  defect  from  a 
circumscribed  .labyrinthitis.) 

In  the  diffuse  serous  secondary  labyrinthitis,  we  have 
an  extension  of  such  a  circumscribed  inflammation  into  the 
labyrinth. 

In  the  diffuse  jjurulent  labyrinthitis,  the  entire  labyrinth 
is  filled  with  pus,  or,  if  the  process  is  already  an  old  one, 
then  with  the  organized  residuum  of  a  purulent  inflamma- 
tion, that  is,  with  granulations,  connective  tissue  or  even 
newly  formed  bone. 

In  the  circumscribed  or  diffuse  serous  secondary  laby- 
rinthitis, we  find  almost  always  but  a  single  point  of  en- 
trance, while  in  the  purulent  labyrinthitis,  the  point  of  en- 
trance, because  of  the  extensive  destruction  of  the  walls,  is 
no  longer  to  be  determined;  often  there  are  two  or  more 
points  of  entrance  which  occurred  at  different  times.  Some 
authors  {Fried rich ,  Laiige)  regard  these  as  secondarily  oc- 
curring points  of  egress  from  the  labyrinth. 

In  the  circumscribed  or  diffuse  serous  secondary  laby- 
rinthitis, the  horizontal  semicircular  canal  is  by  far  the 
most  frequent  ])ortal  of  entrance ;  in  purulent  labyrinthitis, 
the  invasions  through  the  oval  window  predominate.  The 
reason  for  this  we  must  look  for  in  the  fact  that  tli,e  likeli- 
hood of  an  extension  into  the  entire  labyrinth  is  greater 
from  the  oval  window  than  from  the  horizontal  semicircular 
canal.  Invasion  through  the  round  window,  contrary  to 
other  writers  {Fried rich,  Meyer),  we  found  less  often. 

In  our  fifty  cases  of  circumscribed  labyrinthitis,  the 
point  of  invasion  occurred  thirty-one  times  in  the  hori- 
zontal semicircular  canal,  three  times  through  the 
oval  window,  once  through  the  horizontal  semi- 
circular canal  and  oval  window,  once  the  frontal 
semicircular  canal,  once  the  promontory;  once  there 
was  an  extensive  sequestrum  so  that  the  point  of  en- 
trance could  not  be  determined ;  in  three  cases  the  fis- 


30  DISEASES  OF  THE  LABYRINTH 

tula  was  not  found,  five  cases  were  not  operated  and 
in  three  cases  the  fistula  developed  after  a  radical 
operation. 

Of  the  twenty  purulent  manifest  labyrinthites,  the 
site  of  the  fistula  was  not  recorded  five  times,  four 
times  no  fistula  was  found,  four  times  the  fistula  oc- 
curred in  the  horizontal  semicircular  canal,  four  times 
in  the  oval  window;  twice  the  labyrinth  wall  was  de- 
stroyed, one  case  was  a  suppuration  after  a  gun- 
shot wound,  in  which  the  ball  lay  in  the  region  of  the 
oval  window. 

Of  twenty-six  cases  of  purulent  latent  labyrinthitis, 
the  fistula  occurred  nine  times  in  the  horizontal  semicir- 
cular canal,  five  times  no  fistula  was  found,  four  times 
it  was  found  in  the  oval  window,  three  times  nothing 
was  observed  (by  way  of  a  fistulous  opening),  twice 
it  was  found  to  be  in  the  horizontal  canal  and  the  oval 
window,  once  in  the  horizontal  and  sagittal  semicircu- 
lar canals,  once  in  the  horizontal  and  frontal  semicircu- 
lar canals,  and  once  there  was  destruction  of  the  laby- 
rinth wall. 

When  we  consider  all  of  the  ninety-six  cases  to- 
getjier,  the  fistula  occurred  forty- four  times  in  the  hori- 
zontal semicircular  canal,  eleven  times  in  the  oval  win- 
dow, once  in  the  frontal  semicircular  canal ;  once  it  was 
localized  in  the  promontory,  five  times  there  was  a 
double  fistula,  three  times  occurring  in  the  horizontal 
semicircular  canal  and  in  the  oval  window,  once  in  the 
horizontal  and  sagittal  canals,  once  in  the  horizontal 
and  frontal  canals;  twelve  times  no  fistula  was  found, 
eight  times  no  fistula  was  noted,  five  cases  were  not 
operated,  so  nothing  can  be  said  regarding  the  loca- 
tion of  the  fistula ;  three  times  the  fistula  occurred  after 
a  radical  operation,  and  so  in  these  cases  also  the  loca- 
tion of  the  fistula  is  undesignated,  and  one  case  was  a 
arunshot  wound. 


ETIOLOGY  31 

From  these  figures  we  see  the  tendency  of  fistiilae  to  be 
located  in  the  horizontal  semieircular  canal.  This  is  rela- 
tively greatest  in  the  circumscribed  suppurations  (thirty- 
one  times  in  fifty  cases),  but  for  the  diffuse  purulent  forms 
less,  namely,  thirteen  out  of  forty-six  cases.  The  relative 
frequency  of  the  fistula  in  the  oval  window  in  the  diffuse 
purulent  labyrinthitis  (eight  out  of  forty-six  cases),  com- 
pared with  the  circumscribed  labyrinthitis  (three  out  of 
fifty  cases),  as  well  as  the  frequency  of  the  double  fistulae 
in  diffuse  purulent  labyrinthitis  (four  out  of  forty-six 
cases),  compared  with  the  circumscribed  labyrinthitis  (one 
out  of  fifty  cases),  is  easily  accounted  for  by  the  above. 

That  we  were  unable  to  find  a  fistula  in  twelve  cases  in 
spite  of  search  after  aspirating  the  blood  with  the  Tonogen 
pump  is  no  proof  that  a  fistula  was  not  present,  but  only 
proves  how  difficult  it  is  to  discover  small  breaks  of 
continuity. 

They  are  especially  easily  overlooked  when  they  do  not 
lie  in  the  horizontal  semicircular  canal,  but  are  localized  at 
some  other  point  in  the  labyrinthine  wall. 

B.    ETIOLOGY 

Nearly  all  circumscribed  and  the  diffuse  purulent  laby- 
rinthites  have  their  cause  in  chronic  middle  ear  suppuration. 
Seldom  do  they  occur  in  consequence  of  an  acute  otitis.* 

Of  our  ninety-six  labyrinthites,  eighty-one  occurred 
in  chronic  otitis,  ten  in  subacute  otitis  ,and  five  in  pro- 
nounced acute  otitis.  Of  the  subacute  suppurations, 
eight  were  of  the  circumscribed  type  and  two  cases  were 
of  the  diffuse  purulent  manifest  labyrinthitis.  The  five 
cases  of  labyrinthitis  growing  out  of  an  acute  otitis 
were  all  of  the  diffuse  purulent  manifest  type. 


*  In  a  case  reported  by  me  previously  the  fistula  in  the  semicircular  canal 
without  doubt  appeared  in  the  course  of  an  acute  otitis.  In  a  case  of  E. 
Vrbantschitsch,  there  occurred  on  the  thirty-ninth  day,  in  the  course  of  an 
acute  traumatic  otitis,  a  labyrinthine  fistula. 


32  DISEASES  OF  THE  LABYRIXTH 

On  the  other  hand,  the  eirouniscribed  labyrinthitis 
appears  frequently  as  the  consequence  of  subacute  or 
chronic  tubercular  suppuration.  At  least,  we  must  so 
interpret  it,  when  out  of  eight  cases  of  circumscribed 
labyrinthitis  occurring-  after  subacute  suppuration,  six 
were  the  subjects  of  advanced  phthisis.  The  figures  of 
Goerke,  who  reports  tuberculosis  as  the  cause  in  five 
cases  out  of  sixteen,  corroborate  the  same  conclusion.* 

Cholesteatoma  also  appears  to  play  an  important 
role  in  the  etiolog}'.  Of  the  ninety-six  cases,  it  was 
positively  observed  during  operation  thirty-one  times, 
fifty-four  times  it  was  not  noted,  nor  was  tuberculosis. 
But  of  these  fifty-four  cases,  some  might  still  have  been 
reckoned  with  those  that  were  cholesteatomatous,  and 
surely  some  belonged  to  the  tubercular.  There  remain 
six  cases  that  were  not  operated,  and  therefore  could 
not  be  controlled.  Four  of  these  were  tubercular  in  an 
advanced  stage. 

The  role  which  cholesteatoma  and  tuberculosis  play  in  cir- 
cumscribed and  diffuse  latent  labyrinthitis,  and,  on  the  other 
hand,  which  acute  otitis  plays  in  diffuse  purulent  manifest 
labyrinthitis,  is  easily  explained.  For  the  formation  of 
both  of  the  first  forms  there  is  necessary  a  slowly  pro- 
gressive bone-destroying  tendency  on  the  part  of  the 
primary  suppurative  disease  in  the  ear.  (See  the  Histo- 
logical Poindings  of  Politzer,\  Ruttm,X  Hegener.%)  The 
genuine  acute  otitis  has  not  at  all  such  a  marked  bone- 
destroying  tendency  as  to  break  through  the  labyrinthine 
capsule.  At  most,  it  would  be  expected  to  force  a  way 
through  the  labyrinth  window.  In  such  an  acute  form  there 
occurs  a  sudden  breaking  through,  and  the  pus  of  the  acute 

*  The  Inflanmiatory  Diseases  of  the  Labyrinth.     Arch.  f.  O.  80. 

tLabyrinth  Findings  in  Chronic  Middle  Ear  Suppuration.    Arch.  f.  O.  LXV. 

tComnumioations   on   the  Histology  of  Labyrinth  Suppurations.    Passow's 
Reports,  Vol.  1,  H,  5  &  6. 

§I>abyrinthitis  and  Brain  Diseases.     Passow's  Reports,  Vol.  IL 


ETIOLOGY  33 

otitis  contains  germs  of  such  virulent  activity  that  we  can 
only  conceive  of  a  rapid  deluging  of  the  labyrinth  with  pus 
(with  rapid  destruction).  Only  in  the  suppuration  of  scar- 
let fever  have  we  observed  rapid  bone  destruction  in  acute 
stages  (Schelbe) ;  but  then  there  also  naturally  results  a 
sudden  invasion  of  the  labyrinth.  On  the  other  hand,  we 
can  ascribe  to  cholesteatoma  and  tuberculosis  a  slow  bone 
destruction. 

A  chronic  purulent  otitis  which  leads  to  a  labyrinthine 
disease  is  ordinarily  of  long  duration,  the  longest  (Case 
38)  thirty-six  years. 

The  original  illness  leading  to  an  otitis  could  for  the  most 
part  not  be  ascertained;  most  often,  however,  scarlet  fever 
and  measles  were  reported. 

It  is  of  great  interest  that  in  certain  cases  (4,  7  and 
9)  the  fistula  into  the  labyrinth  formed  not  until  a  consid- 
erable period  after  the  radical  operation,  in  the  stage  when 
the  wound  was  covered  with  granulations.  In  Case  4  it  is 
remarkable  that  seventeen  days  after,  the  operation,  in 
spite  of  the  fact  that  the  cavity  was  covered  with  granula- 
tions, the  semicircular  canal  was  bare,  though  no  fistula 
could  be  discovered.  Not  until  six  months  later  was  the  pa- 
tient again  admitted  and  operated,  after  which  the  fistula 
symj)tom  could  be  observed.  At  the  operation  there  ap- 
peared in  fact  a  fistula  in  the  horizontal  semicircular  canal. 
In  Case  7,  not  until  four  months  later,  though  the  region 
of  the  lateral  semicircular  canal  was  epidermized,  was  the 
fistula  symptom  demonstrable.  In  Case  9,  the  fistula  symp- 
tom was  plain,  though  at  the  time  of  the  operation,  which 
was  ])erformed  with  avoidance  of  the  tympanic  membrane, 
the  ojierator  remarked  especially  that  the  semicircular  canal 
was  healthy. 

It  would  appear  that  here  the  belated  fistula  had  devel- 
oped at  a  point  in  the  labyrinth  wall  which  had  formed 
along  a  tract  before  the  operation. 

This  knowledge,  that  a  labyrinthine  fistula  is  capable  of 
slowly  developing  in  the  course  of  months  after  the  radical 


34  DISEASES  OF  THE  LABYRINTH 

operation,  along  a  tract  already  preformed,  appears  to  us 
of  moment  for  the  prognosis  of  the  radical  operation.  Prob- 
ably such  cases  of  chronic  middle  ear  suppuration  with  at- 
tacks of  vertigo,  in  which  we  are  in  no  way  able  to  prove 
a  positive  labyrinthine  disease,  in  consideration  of  what 
has  been  said  above,  should  warn  us  to  think  of  the  possi- 
bility of  disease  of  the  labyrinth  wall  of  a  progressive 
character,  which  we  may  designate  diaguostically  under  the 
somewhat  uncertain  clinical  term  paralahyrinthitis. 

Particularly  worthy  of  notice  is  Case  6,  in  which  the  fis- 
tula symptom  was  demonstrable  with  a  non-perforated,  non- 
inflamed  tympanic  membrane.  We  can  never  forget  the 
possibility  that  such  a  case  is  to  be  counted  among  the  puru- 
lent ones.  How  perfectly  an  attic  perforation,  for  instance, 
is  ca^pable  of  healing  is  illustrated  by  the  following  exam- 
ple: A  girl  from  whom  I  removed  a  long  pedicled  attic 
poljT)  which  reached  to  the  external  canal,  and  in  whom  I 
demonstrated  in  my  course  the  attic  perforation,  passed 
from  under  our  observation  and  months  later  returned  to 
the  clinic,  by  chance,  in  the  course  of  my  colleague.  Dr. 
Bondy.  He  was  unwilling  to  believe  the  girl  when  she  said 
I  had  removed  a  polyp  until  I  had  myself  confirmed  her 
statement,  so  completely  had  the  membrane  healed.  Indeed, 
it  is  perhaps  exceptionally  permissible  to  assume  the  occur- 
rence of  a  spontaneous  dehiscence  in  the  semicircular  canal. 

C.   SYMPTOMS 

In  circumscribed  labyrinthitis  the  transitions  from  the 
latent  to  the  manifest  stage  are  so  variable  and  so  indis- 
tinct that  we  are  unable  to  make  a  clinical  distinction  be- 
tween these  two  stages.  The  labyrinthine  symptoms  (tin- 
nitus, vertigo,  emesis,  disturbances  of  equilibrium,  nystag- 
mus) may  at  the  time  of  examination  be  present  or  absent. 
They  may,  however,  ^luring  the  entire  progress  of  the  dis- 
ease appear  at  any  time  in  the  form  of  attacks,  so  that  a 
patient,  free  from  all  symptoms  during  the  examination,  a 
short  time  thereafter  may  present  severe  symptoms. 


SYMPTOMS  35 

In  the  diffuse  serous  secondary  labyrinthitis,  only  the 
manifest  stage  comes  into  consideration,  for  we  can  no 
longer  consider  as  latent  a  serous  labyrinthitis  which  has 
once  run  its  course. 

On  the  contrary,  in  the  purulent  habyrinthitis  the  mani- 
fest and  latent  stages  are  very  sharply  defined.  In  the 
manifest  stage  there  are  abruptly  appearing  but  slowly 
diminishing  labyrinthine  symptoms  (nystagmus  to  the  non- 
affected  side,  vertigo,  emesis,  equilibrium  disturbances). 
In  the  latent  stage  there  are  no  symptoms,  except  occa- 
sionally a  slight  nystagmus  ordinarily  directed  to  both  sides, 
that  is,  according  to  whether  the  eyes  are  turned  toward 
the  left  or  right.  The  differential  diagnosis,  therefore,  must 
consist  in  distinguishing  between : 

(a)  1.  Circumscribed  labyrinthitis. 

(a)  2.  Diffuse  serous  secondary  labyrinthitis. 

(b)  3.  Diffuse  purulent  manifest  labyrinthitis, 
(b)  4.  Diffuse  purulent  latent  labyrinthitis. 

(a)  differentiates  itself  from  (b)  by  the  presence  of  some 
remnant  of  function  demonstrable  by  our  labyrinthine  tests 
(hearing,  caloric  reaction,  rotation  reaction,  fistula  symp- 
tom) ;  1  from  2  by  the  absence  of  the  so-called  (Vestibnlar- 
ausschaltung symptom)  symptom  of  vestibular  inactivity 
(=  nystagmus  toward  the  healthy  side,  vertigo,  emesis,  dis- 
turbances of  equilibrium) ;  while  in  1  regularly  both  divi- 
sions of  the  labyrinth  functionate,  i.e.  both  hearing  and 
vestibular  reaction  remain;  in  2  the  hearing  is  often  lost, 
more  seldom  also  the  caloric  reaction  and  the  rotation  re- 
action. 3  is  to  be  distinguished  from  4  by  the  failure  of 
the  vestibular  apparatus  to  functionate  (=  nystagmus  to 
the  healthy  side,  vertigo,  emesis,  disturbances  of  equi- 
librium). 

Let  us  consider  the  picture  of  each  of  these  diseases  by 
itself : 

Circumscribed  Labyrinthitis. 
A  patient  with  chronic  purulent  otitis  complains  for  some 


36  DISEASES  OF  THE  LABYRIXTH 

time  of  liavinji;  attacks  of  vertigo,  perhaps  also  of  tinnitus. 
Examination  shows  a  greater  or  lesser  diminution  of  hear- 
ing, hut  this  function  is  by  no  means  lost;  the  fistula  symp- 
tom is  positive,  the  caloric  reaction  present,  spontaneous 
nystagmus  exists,  generally  to  both  sides,  according  to  the 
direction  of  fixation. 

Diffuse  Serous  Secondary  Lahyrintlutls. 

A  patient  who  has  for  some  time  been  under  our  obser- 
vation with  circumscribed  labyrinthitis  suddenly  is  taken 
with  severe  vertigo,  has  marked  rotatory  spontaneous  nys- 
tagmus toward  the  healthy  side,  his  hearing  on  the  diseased 
side  has  become  markedly  worse,  often  is  entirely  lost  or 
there  remains  only  a  very  slight  degree  of  hearing  (for 
loud  speech),  the  caloric  reaction  is  still  demonstrable  or 
is  entirely  lost.  (In  the  last  case  the  patient  is  totally  deaf 
on  the  affected  side.)  Still,  the  fistula  symptom  is 
demonstrable. 

Diffuse  Puruleut  Manifest  Labyrinthitis. 

A  patient  with  chronic  middle  ear  suppuration  suddenly 
has  the  most  severe  vestibular  sjniptonis — marked  vertigo, 
extensive  rotatory  nystagmus  toward  the  healthy  side, 
emesis,  disturbances  of  equilibrium.  The  functional  test 
shows  him  to  be  totally  deaf  on  the  affected  side;  he  does 
not  react  to  the  caloric,  turning  or  fistula  tests;  in  short, 
no  functional  activity  of  the  labyrinth  can  be  shown. 

Diffuse  Purulent  Latent  Labyrinthitis. 

A  patient  who  for  some  time  has  suffered  from  a  chronic 
suppurative  otitis,  relates  that  months  or  years  ago  he  had 
vertigo.  At  the  present  time  there  are  no  symptoms;  at  the 
most,  some  spontaneous  nystagmus,  accordingly  as  his  fixa- 
tion is  to  the  right  or  left.  The  functional  test  shows  com- 
plete obliteration  of  the  labyrinth,  total  deafness,  no  caloric 
reaction,  no  turning  reaction,  no  fistula  symptom  demon- 
strable. 


SYMPTOMS  37 

If  a  diffuse  purulent  latent  labyrinthitis  has  existed  very 
long,  so  that  there  is  a  complete  ossification  of  the  laby- 
rinth, then  the  turning  test  may  apparently  have  been  pre- 
served; that  is,  there  appears  a  manifestation  which  I  have 
designated  as  compensation,  for  which  the  following  expla- 
nation may  be  given :  When  a  labyrinth  has  been  for  a  long 
period  destroyed,  so  that  there  remains  not  the  slightest 
remnant  of  its  sensory  cells  or  nerve  endings,  then  the  other 
labyrinth  takes  up  a  certain  compensatory  function.  That 
is  to  say,  for  example,  if  the  right  labyrinth  is  destroyed, 
but  a  compensation  has  not  yet  appeared,  then  we  would 
have,  after  rotating  to  the  right,  with  head  erect,  an  after- 
nystagmus  to  the  left,  with  a  duration  of  15"  —  30",  after 
turning  to  the  left,  an  after-nystagmus  to  the  right  with  a 
duration  of  5".  Here  the  nystagmus  to  the  right  as  well  as 
to  the  left  in  this  case  originates  in  the  left  labyrinth;  but 
the  impulse  for  nystagmus  to  the  right  through  movement 
of  the  endol\Tapli  in  the  left  horizontal  semicircular  canal 
is  from  the  small  end  toward  the  ampulla  (the  effective 
movement),  but  the  nystagmus  to  the  right  is  caused  by  the 
movement  of  the  endolymph  from  the  ampulla  to  the  small 
end  (the  less  effective). 

If,  however,  compensation  has  already  taken  place,  then 
we  have,  for  example,  if  the  right  labyrinth  is  destroyed,  an 
after-nystagmus  to  the  right  or  to  the  left  lasting  10"  — 15", 
according  to  the  direction  of  rotation,  but  in  the  propor- 
tion of  10"  for  the  left  and  15"  to  the  right.  And  in  this 
case  the  nystagmus  can  originate  only  in  the  left  horizontal 
semicircular  canal,  but  we  must  assume  that  the  movement 
of  endolymph  from  the  smooth  end  to  the  ampulla  is  now 
equally  effective  with  the  movement  from  the  ampulla  to 
the  smooth  end.  According  to  my  observations,  which  I 
have  made  in  part  after  the  completion  of  this  book,  for 
which  reason  I  am  unable  to  introduce  the  case  histories, 
this  compensation  occurs  only  in  cases  in  which  the  com- 
plete labyrinth  destruction  has  existed  a  long  time;  for  in- 
stance, with  ossification  or  sequestration.    It  is  demonstra- 


38  DISEASES  OF  THE  LABYEIXTH 

ble  equally  well  for  horizontal  and  rotatory  nystagmus,  tins 
corresponding  with  the  position  of  the  head.* 

On  the  other  hand,  a  series  of  cases  with  labyrinth  opera- 
tions and  other  cases  in  which  we  could  not  assume  that 
there  was  a  complete  destruction  of  all  nerve  endings  did 
not  show  this  compensation  even  after  several  years. 

It  is  to  be  noted  that  the  diffuse  purulent  latent  laby- 
rinthitis sometimes  occurs  with  necrosis  and  sequestration 
of  the  labyrinth.f 

As  a  rule,  in  sequestration  of  the  labyrinth  the  following 
symptom  triad  occurs  in  the  diseased  ear :  Total  deafness, 
loss  of  irritability  of  the  vestibular  apparatus  for  tlie  ca- 
loric, turning  and  mechanical  stimuli,  and  facial  paralysis. 
Yet  it  is  possible  that  the  turning  reaction  may  have  ap- 
parently returned,  inasmuch  as  compensation  may  have 
taken  place.  Whether  this  will  be  the  case  apparently  de- 
pends upon  the  duration  of  the  process  and  the  complete- 
ness of  the  destruction  of  the  nervous  elements.  That  in 
spite  of  almost  complete  necrosis  or  sequestration  of  the 
labyrinth,  the  soft  parts  of  the  labyrinth  must  not  neces- 
sarily be  destroyed  is  proved  by  Cases  12  and  29,  in  which, 
notwithstanding  the  extensive  necrosis  of  the  labyrinth  con- 
taining bone  with  sequestration,  the  fistula  symptom  was 
still  present.  Two  more  cases  of  this  type  are  reported  in 
the  literature  {Ruttin,E.  Urbantschitsch). 

The  facial  paresis  or  paralysis  need  not  always  be  pres- 
ent, but  is  a  very  frequent  symptom  (according  to  Bezold, 
in  83%  of  the  cases;  according  to  Gerber,  in  77%).  It  is 
generally  caused  by  the  fact  that  the  necrosis  also  involves 
the  facial  canal  lying  in  such  proximity  to  the  labyrinth, 

•  Concerning  the  relation  of  the  sagittal  semicircular  canal  in  these  cases 
I  will  report  later. 

fRegarding  the  formation  of  necrosis  and  sequestration,  I  am  unable 
to  express  myself  further  here.  See  the  works  of  Bezold^,  Oerher^  (with 
extensive  references),  Hegener^,  Siebenmann-yager*,  Friedrich^,  Lange^, 
Whittmaack''.  1.  Labyrinth  Necrosis  and  Paralysis  of  the  Facial  Nerve. 
Wiesbaden,  1886.  2.  Arch.  f.  O.  Bd.  60.  3.  Labyrinthitis  and  Brain  Abscess. 
Passow's  Beitraege,  Bd.  II.  4.  Z.  f.  O.  53.  5.  Suppurations  of  the  Laby- 
rinth.   Wiesbaden,  1905.    6.  Quoted  from  Hegener.    7.  Z.  f.  0.  Bd.  47. 


SYMPTOMS 


39 


but  may  also  be  caused  by  pressure  of  the  sequestrum  upon 
the  facial  {Neumann).  The  determination  whether  or  not 
there  has  been  formed  a  sequestrum  may,  under  certain 
conditions,  be  of  the  greatest  importance.  AVe  have  already 
stated  that  in  case  of  diffuse  purulent  latent  labyrinthitis 
the  so-called  compensation  may  be  present;  that  is,  with 
a  completely  destroyed  labyrinth,  the  nystagmus  after  turn- 
ing may  be  equal  toward  both  sides,  and  that  this  is  an  in- 
dication of  a  long  existing  labyrinthine  destruction,  such 
as  is  caused  by  bony  invasion  of  the  labyrinth  or  by  a 
sequestrum. 

Let  us  arrange  these  clinical  forms,  for  the  sake  of  a 
clearer  oversight,  in  a  table : 


Anamnesis 

to 

6 

03 

3 

s 

bO 
lA 

■*» 
m 

bC 

•c 

C3 

.2  § 

•is 

6^ 

11 

e   o 

u    S3 

^     O 
CO 

Circumscribed 
Labyrinthitis 

Attacks  of 
Vertigo 

+ 

Diseased 
side  or 

^^ 

Healthy 
side  or 

+ 

+ 

• 
4- 

4- 

Diffuse  serous 

secondary 
Labyrinthitis 

Vertigo  for 
some  time 
or  attacks 

+ 

\ 

Healthy 
side 

+ 

+ 

+ 

4- 

Diffuse  Purulent 

Manifest 

Labyrinth'tis 

Vertigo 

present  or 

absent 

+ 

Healthy 
side 

- 

- 

- 

- 

Diffuse  Purulent 

Latent 
Labyrinthitis 

Vertigo  some 
time  ago 

— 

0 
or 

— 

— 

4-  on 
Com- 
pensa- 
tion 

— 

Tiote:     v       V     ::=  Nystagmus    to    right,    on    looking    toward    right,    and 
nystagmus  to  left  on  looking  to  left. 


40  DISEASES  OF  THE  LABYRIXTH 

If  it  is  a  case  of  bony  lienling  of  the  labyriiitliitis,  then 
naturally  an  operation  would  be  .sui)erfluous.  If,  on  the  con- 
trary, it  is  a  ease  of  a  sequestrum,  then  a  labyrinth  opera- 
tion is  naturally  indicated.  Here  the  facial  paralysis  may 
give  the  correct  indication,  for  in  a  case  of  facial  paresis  of 
not  too  long  standing  we  may  assume  with  considerable  cer- 
tainty that  a  necrosis  or  sequestrum  exists. 

AVe  will  now  look  more  closely  at  the  diag-nostic  symp- 
toms and  results  of  the  functional  tests  in  the  order  as 
arranged. 

Anamnesis. 

Vertigo  appearing  in  attacks  is  peculiar  to  circumscribed 
labyrinthitis,  though  this  must  naturally  also  be  given  in 
the  history  of  the  diffuse  secondary  labyrinthitis,  since  this 
is  preceded  by  the  circumscribed  form. 

As  a  rule,  the  vertigo  occurs  very  suddenly,  and  from 
this  time  there  come  attacks  of  vertigo  at  intervals  which 
finally,  bring  the  ])atient  to  the  physician.  These  attacks  of 
vertigo  may  exist  for  years.  In  one  case  (Case  11)  the  at- 
tacks of  vertigo  were  referred  back  five  years.  As  a  rule, 
the  period  varies  between  five  weeks  and  two  days. 

In  one  case  (Case  41)  we  were  able  to  note  the  invasion 
into  the  lal)yrinth  before  our  very  eyes.  The  patient  was 
at  the  clinic  Avaiting  for  operation;  the  examination  for 
labyrinthine  disease  was  negative.  One  day  he  was  taken 
with  severe  vertigo;  the  previously  negative  fistula  symp- 
tom was  now  decidedly  positive. 

In  our  fifty  cases  of  circumscribed  or  diffuse  serous  sec- 
ondary labyrinthitis,  only  nine  gave  no  attacks  of  vertigo 
in  the  anamnesis,  and  of  these  nine,  five  were  advanced 
cases  of  tuberculosis.  In  these  the  absence  of  vertigo  is  to 
be  exi)lained  by  the  slowness  of  the  destructive  tubercular 
process  (Herzog).  All  the  others  (except  two,  concerning 
whose  vertigo  nothing  was  noted)  gave  regularly  a  history 
of  dizziness. 

Ordinarily,  the  beginning  of  the  vertigo  attacks  is  re- 


SYMPTOMS  41 

f erred  back  between  five  weeks  and  two  days;  the  longest 
duration  was  eight  years  (Case  25). 

Present  Symptoms. 

Under  this  heading  we  understand  labyrinthine  symp- 
toms— tinnitus,  vertigo,  emesis,  equilibrium  disturbances; 
also  nystagmus  belongs  here,  though  in  the  table,  for  prac- 
tical purposes,  this  was  separately  tabulated. 

Tinnitus  is  altogether  an  inconstant  symptom.  It  may 
occur  in  all  forms  of  labyrinth  inflammation,  but  in  most 
cases,  relative  to  the  other  symptoms,  it  falls  into  the  back- 
ground, as  compared  with  the  many  eases  of  non-inflamma- 
tory labyrinth  diseases  in  which  tinnitus  is  often  the  most 
trying  symptom. 

It  is  to  be  noted  also  that  tinnitus  may  occur  in  total  de- 
struction of  the  labyrinth,  that  is,  in  purulent  labyrinthitis; 
and,  further,  destruction  of  the  labyrinth  by  operation  does 
not  always  relieve  an  existing  tinnitus  {E.  Urbantschitsch). 
Neinnann  endeavors  to  explain  this  by  assuming  that  the 
tinnitus  is  caused  by  degeneration  of  the  ganglion  cells  in 
the  nerves. 

Of  our  fifty  cases  of  circumscribed  labyrinthitis,  tin- 
nitus was  noted  seventeen  times,  yet  only  twice  was  the 
tinnitus  severe,  for  the  most  part  it  was  reported  as 
only  occasional. 

Of  the  twenty  diffuse  purulent  manifest  cases,  tin- 
nitus was  noted  only  three  times ;  in  the  twenty-six  dif- 
fuse latent  cases,  only  four  times.  It  is  to  be  stated 
that  in  three  cases  (87,  89,  93)  the  tinnitus  continued 
after  the  labyrinth  operation,  and  that  in  one  case 
(92)  the  tinnitus  appeared  after  the  labyrinth 
operation. 

The  attacks  of  vertigo  of  the  circumscribed  labyrinthitis 
we  are  not  often  in  a  position  to  observe.  We  may,  how- 
ever, provoke  them,  if  we  either  have  the  patient  make 
active  movements  of  the  head  or  if  we  passively  move  the 


42  DISEASES  OF  THE  LABYRINTH 

head  forward  and  backward,  or  laterally.  On  the  other 
hand,  we  see  vertigo  appearing  very  often  in  the  diffuse 
serous  secondary  forms,  for  this  comes  on  chiefly  after  the 
radical  operation,  and  we  then  see  it  develop  before  our 
eyes.  Ordinarily,  between  the  first  and  the  third  day  after 
the  radical  operation  occur  marked  nystagmus  toward  the 
healthy  side,  emesis,  disturbances  of  equilibrium  (or  the  pa- 
tient may  assume  a  position  of  preference  [Zivangslage] 
on  the  unaffected  side)  and  vertigo.  These  typical  mani- 
festations we  see  in  our  eleveh  cases  in  which  there  devel- 
oped after  the  operation,  from  a  circumscribed  laby- 
rinthitis, a  diffuse  serous  secondary  labyrinthitis.  In  three 
other  cases  there  was  no  vertigo,  in  spite  of  the  fact  that 
the  same  diseased  conditions  existed  (Cases  40,  43,  48). 
These  manifestations  disappear  on  the  average  in  three  to 
five  days.  There  are  also  cases  in  which  likewise  there  ap- 
pears a  diffuse  secondary  serous  labyrinthitis  which  was 
at  first  suppressed ;  that  is,  there  occur  on  the  day  follow- 
ing the  radical  operation  some  vertigo  and  nystagmus,  but 
this  nystagmus  never  attains  its  severest  form  (third  de- 
gree) ;  the  vertigo  and  nystagmus  pass  rapidly  hj,  and 
there  remain  no  functional  symptoms.  In  the  well  defined 
forms  this  is  regularly  the  case.  There  remain  always  func- 
tional disturbances  (diminished  hearing,  eventually  total 
deafness,  sometimes  also  loss  of  the  caloric  or  turning  re- 
actions), of  which  we  will  later  say  more  in  detail.  In  some 
individual  cases  the  symptoms  appear  to  a  certain  extent 
in  a  desultory  manner;  that  is,  during  the  first  three  days 
there  develop  symptoms  not  at  all  definite — a  little  dizzi- 
ness, nystagmus  of  the  first  or  second  degree  to  the  healthy 
side.  These  symptoms  disappear  again,  and  the  patient 
has  two  or  three  days  of  rest.  On  the  fifth  to  the  sixth  day 
there  appear  suddenly  the  symptoms  of  a  fully  developed 
diffuse  serous  secondary  labyrinthitis  (Cases  30  and  39). 

In  the  diffuse  purulent  manifest  labyrinthitis,  the  laby- 
rinth symptoms  of  nystagmus  to  the  healthy  side,  vertigo, 
emesis,  disturbances  of  equilibrium,  enforced  decubitus  on 


SYMPTOMS  43 

the  healthy  side,  all  appear  in  a  very  marked  way,  unless  the 
IDnrnlent  form  has  developed  slowly  out  of  a  serous  type. 
For  example,  in  Case  70  the  serous  labyrinthitis  began  on 
the  second  day  after  the  radical  operation,  and  the  purulent 
labyrinthitis  developed  at  first  gradually  to  the  ninth  day, 
and  accordingly  the  symjjtoms  were  not  very  marked. 

In  a  co-existing  meningitis  the  symptoms  may  be  consid- 
erably masked.  After  the  labyrinth  operation  the  vertigo 
diminishes  with  the  nystagmus  in  ten  to  seventeen  days. 
In  one  case  (No.  65)  the  nystagmus  completely  disappeared 
immediately  after  the  operation. 

In  the  diffuse  purulent  latent  labyrinthitis  there  are  no 
symptoms,  though  they  are  usually  to  a  greater  or  less  ex- 
tent brought  out  again  by  the  labyrinth  operation.  We  must 
imagine  that  by  the  operation  nerve  cells  and  fibers  still 
capable  of  some  function,  though  they  do  not  respond  to 
our  tests,  are  now  destroyed.  The  duration  of  these  symp- 
toms arising  after  a  labyrinth  operation  is  very  variable, 
according  to  the  completeness  of  the  labyrinthine 
destruction. 

The  longer  the  labyrinth  disease  lasts,  so  much  more 
likely  is  there  a  complete  organization  of  the  exudate, 
eventually  even  a  bony  substitution.  Accordingly,  the  more 
complete  is  the  destruction  of  the  nervous  elements  of  the 
vestibular  apparatus  which  are  imbedded  in  the  exudate. 
In  such  old  cases  the  symptoms  after  the  labyrinth  opera- 
tion are  exceedingly  slight,  but  in  other  cases  in  which  the 
labyrinth  suppuration  is  of  more  recent  date  the  symptoms 
are  often  quite  severe.  According  to  our  experience,  these 
symptoms  last  ordinarily  from  three  to  five  days.  We  have 
never  seen  the  limit  exceed  fourteen  days,  and  during  this 
period  they  always  show  diminishing  severity — a  fact  of 
great  importance  in  the  differential  diagnosis  of  meningitis 
and  brain  abscess. 

Nystagmus. 

In  circumscribed  labyrinthitis  the  nystagmus  is  directed 


44  DISEASES  OF  THE  LABYEIXTH 

at  one  time  to  the  healthy  side,  at  another  to  the  diseased 
side;  again,  it  is  directed  to  both  sides,  or  there  may  be  no 
nystagmus  present.  This  corresponds  with  our  theoretical 
assumption,  for  we  know  that  from  each  labyrinth,  by  irri- 
tation, nystagmus  may  be  produced  to  the  right  as  well  as 
to  the  left.  The  nystagmus  in  circumscribed  labyrinthitis 
we  must  consider  a  symptom  of  irritation.  In  our  Cases 
1,  3,  4,  6,  7,  8,  9,  11,  12,  14,  17,  18,  19,  25,  26,  27,  30,  31,  34, 
35,  36,  38,  39,  40,  41,  42,  43,  45,  46,  47,  48  and  50,  which 
before  tlie  operation  we  regarded  as  cases  of  pure  circum- 
scribed labyrinthitis,  there  occurred  nineteen  times  no  nys- 
tagmus; fourteen  times  nystagmus  to  both  sides,  that  is, 
in  extreme  lateral  fixation  of  the  eyes.  Only  once  was  there 
nystagmus  to  the  healthy  side.  However,  in  the  diffuse 
labyrinthitis,  as  well  as  in  the  serous  and  in  the  purulent 
manifest  form,  we  encounter  a  nystagmus,  since  it  also  oc- 
curs after  operative  destruction,  which  we  must  regard  as 
called  forth  by  the  preponderance  of  the  well  side.  This  is 
the  severest  grade  of  nystagmus  to  the  healthy  side,  with, 
of  course,  the  gradual  dying  out  of  the  symptom.  In  the 
diffuse  purulent  latent  labyrinthitis,  nystagmus  is  entirely 
absent;  that  is,  it  has  run  its  course  before  the  time  of  our 
observation. 

Acuteness  of  Hearing. 

In  the  pure  circumscribed  labyrinthitis  we  find  regularly 
a  more  or  less  well-j^reserved  hearing  power.* 

Of  our  fifty  cases,  thirty-three  had  hearing  and  sev- 
enteen were  deaf.  Of  these  thirty-three,  nineteen  had 
a  hearing  power  of  more  than  one  meter  (the  greatest 
I  was  six  meters).  These  were  clear  circumscribed  laby- 
rinthites;  fourteen  had  a  hearing  of  less  than  one 
meter,  of  whom  eleven  were  pure  circumscribed  and 

*  Schmiegelow  (Arch.  f.  O.  79)  found  in  his  cases  rejiularly  deafness,  though 
he  himself  makes  the  significant  observation  that  this  was  probably,  with 
his  limited  material,  a  coincidence. 


SYMPTOMS  45 

six  were  diffuse  serous  secondary  labyrinthitis. 
Of  the  seventeen  deaf  cases,  six  were  of  the  diffuse 
serous  secondary  type,  which  were  diagnosed  as  such 
from  other  symptoms,  one  a  purulent  manifest  arising 
from  a  circumscribed  labyrinthitis,  seven  were  tuber- 
cular, very  likely  also  serous  labyrinthites  which  had 
run  their  course,  which  is  so  often  true  in  the  tuber- 
cular cases,  as  Herzog  and  I  myself  have  already  sug- 
gested. Two  cases  were  previously  deaf,  and  one  was 
deaf  on  both  sides,  the  deafness  having  come  from 
other  causes. 

Of  the  thirty-three  cases  with  hearing,  eight  became 
deaf  after  the  radical  operation  (Nos.  1,  3,  14,  26,  31, 
43,  45,  50).  All  of  these  showed  signs  of  a  diffuse 
serous  secondary  labyrinthitis.  Of  the  remaining 
twenty-five  cases,  only  three  had  the  symptoms  of  a 
serous  labyrinthitis  (Nos.  23,  32,  49).  Two  of  these  re- 
tained their  hearing  after  the  subsidence  of  the  serous 
labyrinthitis.  In  the  third  case,  the  labyrinth  opera- 
tion was  performed  (No.  32). 

From  these  figures  we  may  conclude  that  the  cases  with 
a  circumscribed  labyrinthitis  have  a  more  or  less  useful 
hearing  power,  and  that  a  spontaneous  labyrinthitis,  or  one 
occurring  after  and  probably  in  consequence  of  a  radical 
operation  may  obliterate  the  hearing  function. 

In  the  diffuse  purulent  labyrinthitis,  both  manifest  and 
latent,  naturally  there  is  always  total  deafness  on  the  af- 
fected side.  Only  in  the  purulent  manifest  labyrinthitis  is 
it  possible  to  have  in  the  very  first  stages  some  hearing 
power,  which,  however,  can  persist  only  a  very  short  time. 
Two  observations,  one  by  Bdrdny  and  one  by  Bondy,  con- 
firm this. 

Caloric  Reaction. 

Of  our  fifty  eases  of  circumscribed  or  diffuse  serous 
secondary  labyrinthitis,  the  caloric  reaction  was  re- 


46  DISEASES  OF  THE  LABYEIXTH 

tained  in  thirty-six  cases,  both  before  and  after  the 
radical  operation,  in  so  far  as  the  labyrinth  operation 
was  not  performed. 

In  seven  cases  the  caloric  reaction  was  lost  before 
the  operation ;  of  these  seven,  four  already  before  the 
operation  showed  the  symptoms  of  a  diffuse  serous  sec- 
ondary labyrinthitis;  in  two  cases  (Nos.  2  and  44)  it 
bad  already  clearly  run  its  course,  and  in  one  case  (No. 
10)  it  developed  before  the  operation  into  a  purulent 
labyrinthitis. 

Seven  more  cases  lost  their  caloric  reaction  through 
a  diffuse  serous  secondary  labyrinthitis,  clearly  the  re- 
sult of  a  radical  operation.  In  all  cases  with  lost  ca- 
loric reaction  the  hearing  was  lost,  with  one  single  ex- 
ception (Case  No.  48). 

Accordingly,  we  may  state:  In  the  circumscribed  laby- 
rinthitis both  hearing  and  caloric  reaction  are  retained. 
Through  the  onset  of  a  diffuse  serous  secondary  laby- 
rinthitis, whether  spontaneous  or  in  consequence  of  the  rad- 
ical operation,  the  hearing  is  lost  more  often  than  the  ca- 
loric reaction.  In  a  series  of  cases  the  hearing  and  the 
caloric  reaction  both  are  lost — clearly  severe  cases.  The 
caloric  reaction  is  never  lost  with  retained  hearing  power 
(exception,  Case  No.  48). 

In  the  purulent  manifest,  as  well  as  latent  labyrinthitis, 
the  caloric  reaction  is  naturally  always  destroyed. 

Turning  Reaction. 

In  general,  the  turning  reaction  is  retained  when  the  ca- 
loric reaction  is  retained.  Yet  the  caloric  reaction  is  the 
finer  test,  in  that  to  be  elicited  it  requires  a  greater  move- 
ment of  the  endolymph  than  does  the  turning  reaction.  Ac- 
cordingly, there  are  cases  in  which  the  caloric  reaction  is 
lost  while  the  turning  reaction  remains.  In  the  pure  cir- 
cumscribed labyrinthitis,  the  turning  reaction  is  always  re- 
tained (Nos.  18,  31,  35,  36,  39,  46,  47).    The  onset  of  a  dif- 


SYMPTOMS  47 

fuse  serous  secondary  labyrinthitis  can,  simultaneously 
with  the  loss  of  hearing  and  of  the  caloric  reaction,  also 
cause  the  loss  of  the  turning  reaction  (Nos.  10,  16,  22,  44). 
Nevertheless,  in  diffuse  serous  secondarj^  labyrinthitis,  the 
hearing  is  alone  most  commonly  lost;  less  often,  hearing, 
caloric  and  turning  reactions.  Very  seldom  do  we  have  loss 
of  hearing  and  the  caloric  reaction,  with  retained  turning 
reaction,  after  the  radical  operation.  Only  once  did  we  ob- 
serve loss  of  turning  reaction  with  retained  hearing  and 
retained  caloric  reaction  (No.  48).  This  case  belongs  to 
the  exceptions  and  does  not  agree  with  our  theoretical  as- 
sumptions. Equally  rare  and  difficult  of  explanation  is  the 
loss  of  the  caloric  reaction  with  retained  hearing  and  turn- 
ing reaction  (No.  47  before  the  radical  operation). 

From  the  above,  we  may  divide  the  diffuse  serous  second- 
ary labyrinthitis  into  the  following  grades: 

Caloric  Turning 

Hearing  Reaction  Reaction  Fistula 

+  +  +  + 

-  -f  +  + 

-  -  +  + 


The  fifth  grade  cannot  be  differentiated  froin  the  puru- 
lent manifest  labyrinthitis. 

In  those  cases  in  which  the  turning  reaction  was  tested 
before  and  after  the  diffuse  serous  secondary  labyrinthitis, 
the  numerical  value  in  seconds,  when  the  turning  reaction 
remained  at  all  after  the  serous  labyrinthitis  had  run  its 
course,  was  less,  as  a  rule,  for  both  sides. 

Case    1 :  before  the  serous  labyrinth-  f  R.  Turning,  Nys.,  horiz.,     left  20" 
itis  (right  ear  diseased)  1  R.  Turning,  Nys.,  horiz.,     left  20" 

After  the  serous  labyrinthitis    )  R.  Turning,  Nys.,  horiz.,      left  12" 

I  L.  Turning,  Nys.,  horiz.,  right  12" 

Case  37 :  before  the  serous  labyrinth-  f  R.  Turning,  Nys.,  horiz.,     left  25" 
itis   (left  ear  diseased)  1  L.  Turning,  Nys.,  horiz.,  right  24" 

After  tlie  serous  labyrinthitis,  \  R.  Turning,  Nys.,  horiz.,      left  10  -14" 
two  months  later  \  L.  Turning,  Nys.,  horiz.,  right  24" 


I. 

Grade 

II. 

11 

III. 

1 1 

JY. 

n 

V. 

n 

48  DISEASES  OF  THE  LABYRIXTn 

Case  39:  before  the  serous  labyrinth- C  R.  Turning,  Nys.,  horiz.,     left  25" 

itis  (right  ear  diseased)'  1  L.  Turning,  Nys.,  horiz.,  right  10  -12" 

After  the  serous  labyrinthitis,  |  R.  Turning,  Nys.,  horiz.,      left  14" 

one  month  later        *  \  L.  Turning,  Nys.,  horiz.,  right     8" 

Case  47:  before  the  serous  labyrinth- C  R.  Turning,  Nys.,  horiz.,      left  32" 

itis   (left  ear  diseased)  1  L.  Turning,  Nys.,  horiz.,  right   15" 

After  the  serous  labyrinthitis    f  L.  Turning,  Nys.,  horiz.,  right  20" 

I  L.  Turning,  Nys.,  horiz.,  right  20" 

We  find  in  the  recorded  cases,  as  well  as  in  other  exam- 
ined cases,  differences  which  show  the  affected  side  to  be 
less  irritable.  But  we  cannot  ascribe  to  these  differences 
any  diagnostic  value.  Only  when  the  differences  are  so  no- 
ticeable that  in  turning  toward  the  healthy  side,  that  is, 
from  the  diseased  side  there  is  practically  no  after- 
nystagmus,  or  one  of  the  briefest  duration,  while  the  dura- 
tion of  the  nystagmus  produced  by  turning  toward  the  dis- 
eased side,  that  is,  the  nystagmus  proceeding  from  the 
healthy  labyrinth,  is  nearly  normal  (between  20"  —  SO")* 
Only  under  these  conditions  do  we  conclude  that  there  is  an 
absence  of  the  reaction  on  the  diseased  side.  Many  cases 
of  labyrinth  disease,  however,  while  confined  to  bed  can- 
not be  tested  for  the  turning  reaction.  This  influences  very 
much  the  value  of  this  test,  particularly  in  those  cases  of 
diffuse  serous  secondary  labyrinthitis,  following  a  circum- 
scribed labyrinthitis  immediately  after  the  radical  opera- 
tion. The  turning  test,  as  regards  its  delicacy  of  reaction 
upon  the  vestibular  apparatus,  is  between  the  caloric  test 
and  the  fistula  test.  The  caloric  reaction  may,  indeed,  be 
already  lost,  and  the  turning  reaction  remain  present;  but 
if  the  turning  reaction  is  not  lost,  then  surely  the  much 
coarser  test  for  fistula  is  positive,  so  that  we  find  the  caloric 
test  and  the  fistula  test  in  these  cases  sufficient  in  order  to 
give  us  a  picture  as  to  the  condition  of  the  vestibular 
apparatus. 

We  will  now  consider  the  figures  for  the  turning  nystag- 
mus in  the  purulent  labyrinthites : 


SYMPTOMS 

49 

isease 

;d  side 

12'' 

Healthy  side 

16" 

10" 

20" 

15" 

20" 

5" 

30" 

— 

(20") 

8" 

16" 

trace  (!) 

trace  (?) 

— 

(20") 

12" 

21" 

10" 

15" 

10" 

26" 

1" 

21" 

2" 

15" 

10" 

40" 

— 

20" 

— 

20" 

Case  55 

62 

65 

71 

72 

74 

77 

81 

83 

84 

86 

90 

92 

93 

95 

96 

Note:  Naturally,  for  example,  ''diseased  side  12" 
and  healthy  side  16""  means  that  after  turning  to  the 
healthy  side  and  stopping  (irritation  of  the  diseased 
side)  after-nystagmus  to  the  diseased  side  lasting  12" 
results,  and  after  turning  to  the  diseased  side  and  ar- 
resting the  movement  (irritating  the  sound  side) 
after-nystagmus  to  the  healthy  side  lasting  16"  occurs. 
The  bracketed  figures  are  the  average  time  which  in 
the  history  were  recorded  as  ''typical"  or  "normal." 

From  the  figures  given,  we  see  at  once  that  in  most  cases 
there  is  a  difference  between  the  duration  of  the  nystag- 
mus of  the  healthy  and  the  diseased  sides,  the  duration  for 
the  healthy  side  being  more  than  twice  that  for  the  diseased 
side.    But  in  normal  cases  we  also  notice  great  differences. 

Bdrdny  has  already  given  the  average  difference  for  per- 
sons with  one-sided  labyrinth  destruction  as  from  14"  to 
28".  Practically,  for  the  diagnosis  I  consider  as  significant 
only  those  cases  in  which  the  after-nystagmus  for  the  af- 
fected side  gives  a  duration  of  at  most  4"  to  5",  compared 
with  a  normal  duration  (20")  for  the  healthy  side.    For  I 


50 


DISEASES  OF  THE  LABYBINTH 


have  not  observed  this  proportion  in  normal  cases,  and 
Bdrdny  has  observed  it  only  very  exceptionally. 

On  the  other  hand,  in  complete  destruction  of  the  laby- 
rinth of  long  standing  (for  example,  after  ossification  or 
sequestration)  a  compensation  of  the  turning  nystagmus 
apparently  takes  place.  My  own  personal  investigations  of 
this  feature  show  that  such  cases  may  have  an  equal  turn- 
ing nystagmus,  while  cases  apparently  destroyed  by  opera- 
tion (yet  not  completely  destroyed),  as  in  one  case,  after 
six  years,  showed  no  compensation.* 

Fistula  Test. 


Fig.  16 


The  demonstration  of  a  fistula  can  be  made  by  inspection 
during  operation.  But  it  is  desirable  before  operating  to 
recognize  the  presence  of  a  fistula.  This  is  done  by  the  so- 
called  fistula  test.  The  reaction  is  present  if,  by  compres- 
sion and  aspiration  of  the  air  in  the  external  auditory  canal 
by  means  of  a  Politzer  bag  armed  with  a  tube  and  olive  tip, 
we  get  either  nystagmus  or  only  a  slow  movement  of  the 
eyes.  We  call  the  nystagmus  typical  when  it  occurs  in  the 
manner  observed  in  the  majority  of  cases ;  that  is,  when  on 

•As  I  have  already  shown,  M.  f.  O.  43,  No,  2. 


SYMPTOMS  51 

compression  we  get  nystagmus  toward  the  affected  side 
(typical  compression  nystagmus),  and  on  aspiration  we  get 
nystagmus  toward  the  healthy  side  (tj^ieal  aspiration 
nystagmus). 

This  was  to  be  noted  in  twenty-four  of  our  fifty  cases. 

A  series  of  cases  in  which  only  ''fistula  symptom" 
was  recorded  {i.e.  eight  cases)  belongs  with  these.  In- 
cluding these,  thirty-two  out  of  fifty  cases  showed  ' '  typ- 
ical nystagmus."  From  this  frequency,  which  was  al- 
ready noticeable  before  we  had  enough  cases  for  statis- 
tical purposes,  and  because  it  is  consistent  with  theo- 
retical grounds,  there  appeared  the  justification  to  des- 
ignate this  nystagmus  as  typical. 

Of  these  thirty-two  fistula  cases  with  typical  nystag- 
mus, the  fistula  was  demonstrated  twenty-six  times  dur- 
ing the  operation.  Four  cases  were  not  operated;  in 
one  case  it  could  not  be  looked  for,  because  of  the  con- 
servative operation  of  Bdrdny;  and  once  the  fistula, 
in  spite  of  a  search  during  the  operation,  could  not  be 
found.  The  location  of  the  fistula  in  these  thirty-two 
cases  occurred  twenty-three  times  in  the  horizontal 
semicircular  canal,  once  in  the  oval  window,  once  in 
the  frontal  semicircular  canal,  and  once  almost  the  en- 
tire pyramid  was  destroyed. 

It  is  also  possible  for  the  nystagmus  in  the  fistula  test 
to  be  reversed,  that  is : 

On  compression,  nystagmus  to  the  healthy  side  (reversed 
compression  nystagnms). 

On  aspiration,  nystagmus  to  the  diseased  side  (reversed 
aspiration  nystagmus). 

Eeversed  nystagmus  in  the  fistula  test  occurred  in 
twelve  cases  out  of  fifty.  In  these,  the  fistula  was  lo- 
cated six  times  in  the  horizontal  canal,  once  in  the 
promontory,  once  in  the  oval  window,  once  in  the  hori- 


52  DISEASES  OF  THE  LABYEINTH 

zontal  canal  and  the  oval  window  in  a  nearly  necrotic 
labyrinth  wall.  Two  cases  were  not  operated;  in  one 
case  the  fistula  appeared  some  time  after  the  radical 
operation. 

From  these  figures  it  follows  that  we  can  draw  no  posi- 
tive conclusion  as  to  the  localization  of  the  fistula*  from  the 
kind  of  fistula  symptom. 

Instead  of  nystagmus,  it  frequently  happens  that  there  is 
only  a  slow  movement  of  the  eyeballs,  and  this  we  call  typi- 
cal when  it  is  of  the  following  character:  With  compres- 
sion, slow  movement  to  the  healthy  side;  with  aspiration, 
slow  movement  to  the  diseased  side;  or  reversed  compres- 
sion movement  and  aspiration  movement;  with  compres- 
sion, slow  movement  to  the  diseased  side,  and  with  aspira- 
tion, slow  movement  to  the  healthy  side. 

A  typical  movement  of  the  eyes  was  present  in  two  cases, 
and  a  reversed  movement  in  one  of  our  cases. 

Ordinarily,  compression  has  a  stronger'  effect  than  aspi- 
ration; less  frequently  the  reverse  is  true  (in  four  cases). 

Correspondingly,  we  may  have,  with  compression,  nys- 
tagmus to  the  diseased  side;  with  aspiration,  only  slow 
movement  to  the  diseased  side  (typical  compression  nystag- 
mus and  typical  aspiration  movement). 

Rarely  is,  the  reverse  true:  With  compression,  slow 
movement  to  the  healthy  side;  with  aspiration,  nystagmus 
to  the  healthy  side  (typical  compression  movement  and 
typical  aspiration  nystagmus). 

It  is  also  possible  that  only  compression  or  only  aspira- 
tion is  effective  (typical  or  reversed  compression  nystag- 
mus, or  only  typical  or  reversed  compression  eye  movement, 
or  only  typical  or  reversed  aspiration  nystagmus,  or  only 
typical  or  reversed  aspiration  eye  movement). 

The  reason  why  we  get  in  the  one  case  nystagmus,  in 
the  other  only  eye  movement,  we  might  assume  to  be  as 
follows:    When  the  irritant,  in  consequence  of  favorable 

•  As  I  have  already  reported,  M.  f.  O.  43,  No.  2. 


SYMPTOMS  53 

pathological-anatomical  relations  (size  of  the  fistula,  free 
accessibility  for  the  compression  air  current),  is  great,  then 
there  follows  close  upon  the  vestibular  irritation,  whose  ef- 
fect is  the  slow  movement  of  the  eyes  to  the  opposite  side, 
the  central  reaction  in  the  form  of  the  rapid,  opposed  move- 
ment. This  produces  a  nystagmus  to  the  same  side. 
On  the  other  hand,  should  the  irritation  produced  by  com- 
pression be  slight,  through  unfavorable  anatomical  rela- 
tions, then  the  vestibular  reaction  is  followed  by  no  central 
reaction,  but  there  follows  after  cessation  of  the  stimulus 
only  a  slow  movement  in  the  opposite  direction  (restoring 
the  eyes  to  their  former  position).  In  fact,  in  such  cases 
the  eyes  remain  in  their  diverted  (abducted)  position  as 
long  as  the  irritation  (compression)  is  in  operation,  and 
return  to  their  ordinary  position  only  when  the  compres- 
sion ceases,  while  in  those  cases  with  nystagmus,  the  quick 
component  appears  during  compression. 

A  fine  example  of  this  is  shown  by  Case  50. 

Here  the  compression  produces  a  typical  movement  of 
the  eyes,  that  is,  a  slow  movement  to  the  right  side  (the 
healthy  side),  and  immediately  following  we  get  the  typical 
nystagmus  to  the  left.  The  central  reaction  comes  equally 
tardy.  With  aspiration  we  get  a  typical  eye  movement, 
that  is,  a  slow  movement  to  the  left  (diseased)  side.  But 
this,  contrary  to  what  we  would  expect,  is  not  followed  by 
a  nystagmus  to  the  right,  but  both  eyeballs,  during  the  en- 
tire period  of  the  aspiration,  remain  fixed  in  the  left 
canthus.  The  weaker  irritation  produced  by  aspiration  is 
not  of  sufficient  force  to  arouse  a  central  reaction. 

Peculiarities  are  shown  by  other  cases  (Case  12).  Nys- 
tagmus under  the  fistula  test  is  quite  typical,  but  aspira- 
tion is  without  effect.  The  operation  showed  a  very  small 
dehiscence  in  the  semicircular  canal,  impassable  to  the 
probe. 

In  a  second  case  (Xo.  48),  with  tA^iical  fistula  symp- 
toms, aspiration  was  entirely  uneffective.  In  this  case  there 
was  a  very  large  cholesteatoma. 


54  DISEASES  OF  THE  LABYRINTH 

The  condition  in  which  the  fistula  symptom  is  only  occa- 
sionally demonstrable,  as  well  as  that  in  which  compression 
is  alone  effective,  seems  to  be  an  indication  that  the  fistula 
is  extremely  small  or  that  it  is  protected  by  an  intervening 
hindrance  (cholesteatoma,  polyp)  from  the  compressing  or 
aspirating  air  current. 

The  fistula  symptom  may  be  unusually  noticeable  or 
easily  provoked.  Often  even  light  pressure  upon  the  tragus 
is  sufficient  to  produce  severe  nystagmus  with  vertigo  and 
falling  movements. 

In  one  case  of  V.  Urhantschitsch,  with  fistula  in  the  hori- 
zontal canal,  on  whom  the  radical  operation  was  performed 
under  local  anaesthesia,  there  appeared  during  the  removal 
of  a  sequestrum,  which  was  wedged  in  between  the  dura  and 
the  pyramidal  bone  toward  the  middle  cranial  fossa,  vio- 
lent vertigo  and  nystagmus,  which  completely  ceased  after 
removal  of  the  sequestrum.  Urhantschitsch  ascribed  this 
manifestation  to  a  second  fistula,  in  the  upper  semicircular 
canal,  which  had  been  closed  by  the  sequestrum. 

At  this  point  it  would  be  w^ell  to  call  attention  to  one 
consideration.  That  is,  the  necessity  of  very  careful  ex- 
amination and  observation  and  also  the  possibility  of  error. 

First,  it  is  possible  to  confuse  the  fistula  nystagmus  with 
the  caloric,  if  one  does  not  most  carefully  avoid  pressure 
during  the  syringing.  (This  is  best  done  by  keeping  the 
irrigator  relatively  low,  i.e.  only  sufficiently  above  the 
meatus  to  cause  a  flow.)  First,  we  may  have  in  the  be- 
ginning of  the  test  a  fistula  nystagmus,  which  we  mistake 
for  a  caloric  reaction.  But  we  notice  that  the  cold  water 
nystagmus  is  directed  toward  the  healthy  side;  therefore, 
cold  water  nystagmus  could  be  confused  only  with  a  re- 
versed compression  nystagmus.  Contrarily,  upon  syring- 
ing with  hot  water,  it  would  be  possible  only  to  confuse  the 
nystagmus  produced  by  the  hot  water  wnth  typical  com- 
pression nystagmus,  for  both  are  directed  toward  the  ex- 
amined side. 
But  we  may,  on  the  other  hand,  also  confuse  the  caloric 


FEVER  55 

nystagmus  -svitli  the  fistula  symptom.  For  instance,  it  is 
possible  in  making  the  fistula  test  to  produce  by  the  air  cur- 
rent employed  a  sufficient  cooling  of  the  labyrinth  wall  as 
to  cause  thereby  a  caloric  nystagmus.  According  to  Bdrdny, 
this  is  particularly  apt  to  be  the  case  when  the  olive  tip 
is  not  inserted  tightly  into  the  meatus. 

Further,  the  confusion  is  possible  only  in  a  case  of  re- 
versed fistula  nystagmus,  for  in  compression  the  typical  fis- 
tula nystagmus  is  to  the  same  side,  the  caloric  (cold)  to  the 
opposite  side. 

But  confusion  with  the  reversed  fistula  nystagmus  can  be 
avoided  if  one  will  observe  that  in  most  cases  in  fistula  nys- 
tagmus not  only  is  compression  effective,  but  a  nystagmus 
is  also  produced  by  aspiration,  and  this  is  in  the  opposite 
direction. 

Further,  it  is  possible  to  confuse  the  fistula  nystagmus 
with  the  associated  nystagmus  of  Stransky.  This  is  an  un- 
dulating nj^stagmus  sometimes  occurring  in  neuropathic  in- 
dividuals, when,  on  having  them  tightly  close  the  eyes,  we 
forcibly  resist  the  effort  with  our  fingers. 

D.   FEVER 

In  order  to  obtain  a  general  idea  of  the  significance  of 
fever  in  labyrinth  diseases,  I  have  divided  the  cases  into 
groups,  as  follows : 

I.  Before  the  operation  under  37°   C (afebrile) 

After     the  operation  under  37°   C (afebrile) 

II.  Before  the  operation  under  37°   C (afebrile) 

After     the  operation  37°  C.-38°  C (subfebrile) 

III.  Before  the  operation  under  37°   C (afebrile) 

After     the  operation  over     38°   C (febrile) 

rV.  Before  the  operation  37°  C.-38°  C (subfebrile) 

After     the  operation  under  37°   C (afebrile) 

V.  Before  the  operati^)n  37°  C.-38°  C (subfebrile) 

After     the  operation  37°  C.-38°  C (subfebrile) 

VI,  Before  the  operation  37°  C.-38°  C (subfebrile) 

After     the  operation  over     38°  C (febrile) 

VII.  Before  the  operation  over     38°  C (febrile) 

After     the  operation  under  37°    C (afebrile) 

VIII.  Before  the  operation  over     38°   C (febrile) 

After     the  operation  37°  C.-38°  C (subfebrile) 

IX.  Before  the  operation  over     38°   C (febrile) 

After     the  operation  over     38°   C (febrile) 


56  DISEASES  OF  THE  LABYRINTH 

A  series  of  cases  not  operated  must  be  eliminated.* 
In  the  first  group,  that  is,  with  normal  temperature  be- 
fore and  after  the  operation,  were  thirteen  easesf.  Of 
these,  two  eases  were  circumscribed  labyrinthitis  (Nos.  19 
and  49) ;  one  case  of  circumscribed  labyrinthitis,  followed 
by  a  secondary  diffuse  serous  labyrinthitis  (No.  32) ;  one 
a  circumscribed  labyrinthitis,  with  a  purulent  manifest 
labyrinthitis  following. (No.  10);  two  cases  of  serous  in- 
duced labyrinthitis  (Nos.  98  and  104) ;  two  cases  of  trauma- 
tism of  the  labyrinth  (Nos.  105  and  107) ;  four  cases  of  puru- 
lent latent  labyrinthitis  (Nos.  72,  89,  92,  93),  and  one  case  of 
purulent  manifest  labyrinthitis  (No.  65).  We  see  that  all 
forms  of  inflammatory  lal)yrinth  disease  may  proceed  with- 
out fever,  a  fact  already  emphasized  by  Friedrich.X  Seven 
of  these  cases  underwent  the  labyrinth  operation,  the  re- 
maining six  had  only  the  radical  operation.  This  proves 
that  neither  after  the  radical  operation  nor  after  the  laby- 
rinth operation  is  it  at  all  necessary  that  we  have  fever; 
but  it  appears  that  the  occurrence  of  a  subfebrile  tempera- 
ture is  very  frequent  after  the  radical  and  labyrinth  opera- 
tions in  circumscribed  and  diffuse  labyrinthitis,  as  a  con- 
sideration of  the  following  group  II  teaches.  To  this  group 
(free  from  fever  before  the  operation,  with  a  subfebrile  tem- 
perature after  operation)  belong  twenty- three  cases.§ 
These  cases  are  partly  circumscribed  (Nos.  1-50), 
partly  diffuse  ])urulent  manifest  or  latent  labyrinthitis 
(Nos.  50-96).  One  case  (No.  100)  is  an  induced  labyrinthi- 
tis. The  subfebrile  temperatures  may  have  existed  before 
operation,  both  in  the  radical  operation  and  in  the  laby- 
rinth operation,  and  may  have  continued  after  the  opera- 
tion, as  shoA\Ti  by  group  Y,  to  which  belong  fourteen  cases.|| 

•Cases  5,  6,   13,  24,  28,  97,   102,  103. 
tCases  10,  19,  32,  48,  65,  72.  89,  92,  93,  98,  104,  105,  107. 
XFriedrich:    Suppuration  of  the  Labyrinth.    Wiesbaden,   1905,  in  Korner's 
Ohrenheilkunde  der  Gegenwart. 

fl^'^«'^n,''n?^,^rSl'  ^^'  ^^'  ^^'  ^''  *-'  ^^'  *"'  *^'  50'  51,  60,  64,  66,  75,  77, 
84,   OS,  91,   96,    100. 

llCases  2,  9,  14,  10,  17,  18,  27,  40,  46,  59,  62,  79,  80,  82. 


FEVER  57 

In  both  groups  there  were  no  deaths.  In  connection  with 
group  I,  and  since  these  subfebrile  temperatures  appear 
quite  regularly  in  all  forms  of  labyrinthitis,  we  are  unable 
to  attach  any  diagnostic  importance  to  the  temperature. 

Let  us  now  consider  group  III,  afebrile  before  the  opera- 
tion, with  post-operative  fever.  To  this  group  belong  eigh- 
teen cases.*  In  six  cases  the  cause  of  the  fever  is  certainly 
not  to  be  found  in  the  labyrinthine  disease,  for  three  cases 
had  a  cerebellar  abscess  (Nos.  11,  12,  70),  one  case  (No. 
43)  is  unexplained,  one  case  (No.  15)  had  severe  tubercu- 
losis, and  one  case  a  carcinomia  with  suppurating  localized 
metastasis. 

There  remain  twelve  cases  in  this  group.  In  these  cases 
there  occurred  a  temperature  after  the  operation,  which 
was  not  to  be  ascribed  to  any  special  labyrinthine  cause. 
Certainly,  we  know  that  after  the  radical  operation  in  un- 
complicated chronic  middle  ear  suppuration  it  is  not  rare 
to  have  an  elevation  of  temperature  of  not  over  38°  C.  It 
is  noteworthy,  however,  that  the  fever,  in  the  two  cases 
which  died  of  post-operative  meningitis,  appeared  not  until 
five  days  after  the  operation  (Cases  33  and  56).  This  would 
seemingly  indicate  that  a  post-operative  meningitis  of  laby- 
rinthine origin  requires  five  days  for  its  development.  One 
fact  thus  brought  out  should  warn  the  operator  in  cases 
of  labyrinth  disease  in  which  only  the  radical  operation  is 
undertaken,  and  that  is  that  the  prognosis  should  not  be 
made  too  favorable.  On  the  other  hand,  this  knowledge 
should  serve  to  give  support  to  our  indications  for  opera- 
tive interference. 

Labyrinthine  symptoms  make  their  appearance  immedi- 
ately after  the  radical  operation  in  those  cases  in  which 
the  labyrinth  has  been  injured.  In  the  development  of  dif- 
fuse labyrinthitis  following  directly  a  previously  existing 
circumscribed  labyrinthine  disease,  they  appear,  as  a  rule, 
within  three  days.     Inasmuch  as  a  meningitis  ordinarily 

•Cases  11,  12,  15,  2G,  33.  39,  43,  45,  56,  57,  63,  70,  83,  86,  87,  95,  106,  108. 


58  DISEASES  OF  THE  LABYElXTn 

develops  from  a  fully  developed  labyrinthitis,  we  are  often 
still  able  to  anticipate  the  meningitis  and  block  the  way  to 
the  cranial  cavity  by  means  of  a  labyrinth  operation,  pro- 
vided we  promptly  take  active  measures  on  noticing  the 
final  positive  indications  of  the  progress  of  a  labyrinthitis, 
that  is,  sudden,  complete  loss  of  labyrinth  function.  If  we 
allow  this  indication  to  go  by  unheeded,  then  the  prospects 
of  mastering  the  meningitis  are  indeed  slight. 

One  exception  is  apparently  given  by  a  case  of  Bondy's, 
in  which  a  meningitis  developed  directly  from  a  serous 
labyrinthitis. 

The  cases  under  group  IV*,  in  which  the  subfebrile  or 
febrile  temperature  before  the  operation  fell  immediately 
after  the  operation,  belong  to  the  exceptions.  On  the  other 
hand,  a  more  or  less  gradual  defervescence,  when  there  was 
fever  before  the  labyrinth  operation,  probably  signifies  that 
the  labyrinthitis  had  already  caused  a  circumscribed  or 
serous  meningitis  in  the  posterior  cerebral  fossa,  and  that 
after  the  primary  purulent  focus  had  been  taken  care  of 
this  meningitis  spontaneously  healed.  This  Avould  be  con- 
firmed by  the  cases  (Nos.  52  and  73)  in  group  Vlll.f  Case 
52,  a  pronounced  meningitis  with  turbid  cerebrospinal  fluid, 
healed  completely  after  the  labyrinth  operation,  at  first 
with  a  rapid  fall  in  temperature,  then  gradual  deferves- 
cence. Case  72  is  particularly  important,  inasmuch  as  it 
involved  the  differential  diagnosis  between  meningitis  of 
the  posterior  fossa  and  brain  abscess.  This  diagnosis  is 
not  to  be  made  from  the  temperature  curve,  for  such  de- 
clines in  temperature  occur  also  in  brain  abscess.  The  case 
was  permanently  cured,  so  that  the  diagnosis  which  we  made 
upon  other  grounds,  to  be  later  referred  to,  was  very  likely 
correct. 

A  fall  in  temperature  before  the  labyrinth  operation 
would  be  naturally  observed  in  cases  in  which  the  labyrinth 
disease  is  combined  with  a  sinus  infection  (of  course,  pro- 

•  Cases  41,   55,   67. 

tCasea  23,  34,  38,  52,  71,  73,  90. 


INDICATIONS  FOR  OPERATION  59 

vided  the  sinus  disease  were  also  relieved  by  operation). 
In  this  class  belong  Cases  7,  23,  34,  38,  90. 

Looking  at  group  IX,*  composed  of  cases  which  had  a 
continuously  high  temperature  before  and  after  the  laby- 
rinth operation,  we  find  that  thej'  are  for  the  most  part  cases 
of  meningitis,  or  of  meningitis  complicated  with  brain  ab- 
scess, existing  before  the  labyrinth  operation. 

From  these  considerations  concerning  the  fever,  we  may 
draw  the  following  conclusions : 

1.  Subfebrile  temperature  immediately  before  and  after 
the  radical  or  the  labyrinth  operation  has  no  significance 
regarding  the  diagnosis  or  the  operative  procedure. 

2.  A  single  elevation  of  temperature  immediately  after 
the  labyrinth  operation  or  at  the  time  of  the  first  change 
of  dressing  is  usually  no  ground  for  anxiety  and  does  not 
indicate  any  complication. 

3.  An  elevation  of  temperature  continuing  several  days 
after  the  radical  or  the  labyrinth  operation,  when  not  oc- 
casioned by  a  co-existing  disease  elsewhere,  is  always  the 
sign  of  an  intracranial  complication,  either  proceeding  from 
a  labyrinth  disease,  or  existing  independently. 

E.  THERAPY,  OR  INDICATIONS  FOR  THE  RADICAL 
AND  THE  LABYRINTH  OPERATIONS 

Disease  of  the  labyrinth,  with  the  exception  of  the  diffuse 
purulent  manifest  labyrinthitis,  does  not  of  itself  signify 
the  necessity  of  an  operative  procedure. 

The  question  now  arises:  Does  the  labyrinth  disease 
make  it  necessary  to  relieve  operatively  the  causal  disease 
(an  acute  or  chronic  middle  ear  suppuration)?  We  may, 
above  all,  take  into  consideration  as  the  causal  disease  only 
the  chronic  middle  ear  suppuration.  For  an  acute  otitis 
practically  never  gives  rise  to  a  circumscribed  or  a  diffuse 
serous  secondary  labyrinthitis,  and  only  exceptionally  to 
a  purulent  labyrinthitis.    On  the  other  hand,  another  com- 

*  Cases  7,  20,  22,  54,  58,  61,  69,   81. 


60  DISEASES  OF  THE  LABYEINTn 

plication  is  not  rare,  i.e.  the  induced  serous  labyrinthitis. 
These  cases  we  will  consider  later. 

But  we  do  not  take  the  ground  that  we  should  operate 
the  moment  we  discover  a  diseased  labyrinth,  for,  sooner 
or  later,  because  of  the  uncertainty  of  our  conservative 
treatment,  we  will  be  forced  to  consider  the  question  of  a 
radical  or  a  labyrinth  operation.  Here  also  the  adage 
priniiim  nil  nocere  applies;  and  in  dealing  with  labyrinth 
diseases,  with  the  exception  of  the  diffuse  purulent  mani- 
fest form,  operation  is  not  urgent.  So  the  question,  "How 
shall  we  operate?"  is  more  Important  than  ''When  shall 
we  operate?"  The  guiding  principle  for  answering  this 
question  must  be  along  the  following  lines : 

If  the  labyrinth  responds  to  only  one  of  our  tests  (hear- 
ing, caloric  test,  turning  test,  fistula  symptom),  then  the 
radical  operation  is  sufficient;  at  least,  it  does  not  endan- 
ger the  life  of  the  patient.  For  an  extension  of  the  disease 
may  be  recognized  in  time,  by  the  further  appearance  of 
labyrinth  symptoms  and  by  the  complete  loss  of  irritabil- 
ity of  the  labyrinth  to  our  knowTi  stimuli;  and  thus  by  a  sec- 
ondary labyrinth  operation  this  may  be  arrested. 

However,  in  case  the  labyrinth  has  already  been  com- 
pletely destroyed  and  no  longer  responds  to  our  known 
stimuli,  then,  if  there  is  an  extension  of  the  disease,  we 
have  no  danger  signal  from  the  labyrinth.  For  the  next 
stage  of  development  does  not  take  place  in  the  labyrinth, 
but  within  the  cranium ;  that  is,  we  recognize  it  by  the  onset 
of  meningitis  symptoms.  Therefore,  in  those  cases  in  which 
the  labyrinth  is  entirely  unresponsive,  we  must  perform 
the  labyrinth  operation  in  combination  with  the  radical 
operation. 

Circumscribed  Labyrinthitis. 

In  the  circumscribed  form  of  labyrinthitis,  according  to 
the  above,  we  perform  only  the  radical  operation.  If,  after 
the  operation,  as  a  rule,  on  the  second  or  third  day,  which 
is  the  critical  time  for  the  appearance  of  a  diffuse  second- 


IXDICATIOXS  FOR  OPERATION  61 

ary  labyrinthitis,  the  symptoms  of  a  unilateral  discontinu- 
ance of  function  of  the  labyrinth  (nystagnms  to  the  healthy 
side,  vertigo,  emesis,  disturbances  of  equilibrium)  appear, 
we  have  to  deal  with  a  diffuse  secondary  or  a  diffuse  puru- 
lent labyrinthitis.  These  are  differentiated  by  the  func- 
tional tests.  We  examine  the  hearing  through  the  dressing 
while  applying  the  exclusion  apparatus  to  the  healthy  ear. 
If  loud  conversation  is  perceived  by  this  test  through  the 
dressing,  further  examination  is  unnecessary,  for  a  diffuse 
purulent  labyrinthitis  is  excluded.  If  the  patient  is  deaf 
upon  the  operated  side  in  this  test,  then  the  dressings  must 
be  removed  and  the  hearing  test  made  again  in  the  same 
manner. .  If  the  patient  again  in  this  examination  proves 
to  be  deaf,  then  we  take  up  the  caloric  test.  If  the  existing 
spontaneous  nystagmus  toward  the  healthy  side  is  only  of 
the  first  or  second  grade,  so  that  we  are  able  to  recognize 
an  increase  in  its  intensity,  then  we  make  the  test  with  cold 
sterile  saline  solution.  But  should  there  be  spontaneous 
nystagmus  of  the  third  degree  to  the  healthy  side,  so  that 
we  would  be  unable  to  recognize  any  increase  of  the  nys- 
tagmus produced  by  syringing  with  cold  saline  solu- 
tion, then  we  must  use  hot  water  (48°  C).  If  the  vestibular 
apparatus  is  still  irritable  to  caloric  stimuli,  then  the  nys- 
tagmus to  the  healthy  side  either  entirely  disappears  or 
becomes  decidedly  weaker,  and  there  appears  a  nystagmus 
toward  the  diseased  side.  If  in  this  manner  the  irritabil- 
ity of  the  labyrinth  to  caloric  changes  can  be  proven,  then 
there  can  likewise  be  as  yet  no  purulent  labyrinthitis.  But 
if  the  labyrinth  does  not  respond  to  the  caloric  test,  then 
we  are  obliged  to  apply  the  fistula  test.  This  is  done  in 
operated  cases  with  a  retro-auricular  opening  by  the  em- 
ployment of  Bdrdny's  rubber  bell,  which  hermetically  cov- 
ers the  entire  operated  field. 

If  the  fistula  symptom  is  present,  then  we  may  again  wait 
until  this  sj^mptom  is  extinguished.  But  if  the  patient  is 
deaf  on  the  operated  side,  is  unresponsive  to  the  caloric 
test,  and  the  fistula  symptom  has  disappeared,  then  we  must 


62  DISEASES  OF  THE  LABYKIMII 

assume  that  a  purulent  labyriiitliitis  has  appeared,  and  the 
labyrinth  operation  must  be  at  once  performed.  For  now 
we  have  passed  the  point  beyond  which  an  extension  of  the 
process  may  still  be  recognized  and  may  without  danger 
be  watched  step  by  step. 

Of  the  thirty-two  cases  of  circumscribed  labyrinthitis,* 
there  occurred  fifteen  times  after  the  radical  operation  a 
diffuse  serous  secondary  labyrinthitis. f  Since  in  every  case 
this  subsided  again,  and  the  labyrinth  never  entirely  failed 
to  respond,  there  never  developed,  according  to  our  experi- 
ence, a  purulent  labyrinthitis,  and  we  had  no  reason  for 
performing  the  labyrinth  operation.  However,  this  opera- 
tion was  performed  in  three  cases,:}:  but  twice  when  there 
was  at  the  same  time  a  cerebellar  abscess  (an  indication 
concerning  which  more  will  be  said),  and  once  because  of 
severe,  trying  attacks  of  vertigo,  on  account  of  which  the 
patient  urged  operation. 

In  the  forty-one§  cases  which  we  must  regard  as  healed 
diffuse  serous  secondary  labyrinthitis,  four  cases  of  ad- 
vanced phthisis  were  not  operated;  upon  three  cases  the 
radical  operation  was  performed,  and  upon  four  the  laby- 
rinth operation  was  performed.  Of  the  last  four,  because 
of  deep  extradural  abscess,  the  labyrinth,  no  longer  intact, 
was  not  avoided.  In  the  other  two  cases  the  labyrinth  opera- 
tion was  performed  without  real  justification  (as  we  now 
know),  for  a  remnant  of  irritability  of  the  labyrinth  re- 
mained; in  the  one  case  (No.  2)  the  fistula  reaction,  in  the 
other  (No.  33)  the  caloric  reaction,  could  be  elicited.  We 
should  state  that  in  the  beginning  cases  like  No.  2,  that  is, 
with  complete  loss  of  hearing  and  of  the  caloric  reaction, 
and  with  the  fistula  symptom  present,  we  regarded  as  ex- 
ceptions, and  we  did  not  rightly  understand  the  relative 

oJ'^o'^V'.l'  *\^'  ^'  ^'  ®'  ^^'  ^2,  14,  17,  18,  19,  25,  26,  27,  30,  31,  34,  35, 
36,  38,  39,  40,  41,  42,  43,  44,   45,  47,  48,  50.  ,       ,       ,       ,     o, 

tCasea  1,  3,  10,  12,  25,  26,  30,  31,  34,  39,  40,  43,  44,  47,  50. 

tCasea  4,  10,  12. 

SCaucs  2,  5,  13,  15,  20,  21,  22,  24,  28,  33,  44. 


IXDICATIONS  FOR  OPERATION  63 

value  of  the  individual  reactions  and  the  sequence  of  their 
destruction.  Therefore,  we  were  inclined  to  treat  these 
cases  as  if  they  were  completely  destroyed  labyrinths ;  that 
is,  to  operate  the  labyrinth.  On  the  other  hand,  the  only 
justification  for  the  labyrinth  operation  in  Case  33  might 
be  the  fact  that  the  patient  had  a  year  before  undergone 
a  radical  operation,  and  that  we  could  promise  him  a  defi- 
nite healing,  with  cessation  of  the  suppuration  of  the  laby- 
rinth wall  onl}^  by  means  of  a  labyrinth  operation.  Finally, 
the  \dolation  of  the  strict  rule  for  operating  brought  sad 
consequences.  The  case  died  of  a  meningitis  six  days  after 
the  labyrinth  operation.  At  the  postmortem  section  I 
looked  carefully  for  a  wound  of  the  dura,  but  could  find 
none,  and  the  path  of  the  suppuration  must  have  been 
through  the  internal  auditory  meatus,  so  that  the  blame 
for  the  results  must  be  assigned  to  the  operation.  This, 
however,  is  the  only  case  in  which  we  can  take  upon  our- 
self  the  blame  for  the  fatal  outcome  in  a  labyrinth  operation. 

Diffuse  Serous  Secondary  Labyrinthitis. 

When  a  patient  with  diffuse  serous  secondary  labyrinthi- 
tis comes  under  observation,  we  wait  for  its  termination. 
It  runs  its  course,  generally  in  a  few  days,  during  which, 
however,  we  regularly  watch  the  function  of  the  labyrinth. 
If,  after  the  termination  of  active  manifestations,  there  re- 
mains any  remnant  of  labyrinth  function  (hearing,  caloric 
reaction,  turning  reaction  or  fistula  symptom),  then  we  per- 
form the  radical  operation,  naturally,  under  the  same  pre- 
cautions as  in  the  circumscribed  labyrinthitis;  that  is,  we 
wait,  so  to  speak,  with  knife  in  hand,  in  order  that  in  case 
of  a  recurrence  of  labyrinth  symptoms  and  the  loss 
of  all  labyrinth  reaction,  we  may  at  once,  on  the  assump- 
tion of  a  purulent  labyrinthitis,  perform  the  labyrinth 
operation. 

It  is  indeed  possible  that  a  diffuse  serous  secondary 
labyrinthitis  might  cause  a  complete  loss  of  labyrinthine 
function;  but  these  cases  we  are  able  to  recognize  only  very 


64  DISEASES  OF  THE  LABYRINTH 

seldom,  and  so  they  must  be  treated  like  the  diffuse  puru- 
lent labyrinthitis;  that  is,  they  must  be  given  the  labyrinth 
operation. 

In  seven  eases*  there  existed  at  the  time  of  admis- 
mission  a  diffuse  serous  secondary  labyrinthitis.  Of 
these,  three  had  the  radical  operation  and  recovered 
completely  without  further  loss  of  function  than  existed 
before  the  operation.  Four  had  the  labyrinth  opera- 
tion, one  case  (No.  10)  because  a  diffuse  purulent 
labyrinthitis  developed  before  our  eyes  (complete  loss 
of  labyrinth  reaction);  one  case  (No.  29)  already 
showed  symptoms  of  meningitis,  and  died  soon  after 
of  meningitis.  A  third  case  (No.  32),  because  of  the 
likelihood  of  a  cerebellar  abscess,  had  the  labyrinth 
operation.  The  fourth  (No.  16)  was  operated  with  not 
altogether  definite  indications,  in  view  of  the  uncer- 
tainty of  the  indications  in  cases  with  loss  of  hearing 
and  of  the  caloric  reaction,  but  with  demonstrable  fis- 
tula symptoms. 

We  awaited  the  subsidence  of  the  acute  stage  in  two 
cases  (37  and  39) ;  in  the  third  case  (23)  we  were  forced 
by  the  presence  of  the  pyaemia  to  operate  earlier. 

Diffuse  Purulent  Manifest  Labyrinthitis. 

In  this  form,  according  to  our  already  stated  rule,  we 
must  perform  the  radical  and  the  labyrinth  operation  in 
one  act,  for  the  labyrinth  is  completely  destroyed,  and  we 
can  no  longer  expect  any  further  information  from  the  laby- 
rinth concerning  the  course  of  the  suppuration.  We  also 
consider  it  imi)erative  to  perform  the  operation  as  quickly 
as  possible,  even  though  many  authors  do  not  dare  to  do 
so,  inasmuch  as  they  prefer  to  wait  for  the  formation  of 
adhesions.  We,  however,  believe  in  the  principle  ubi  pus 
ibi  evacua,  and  that  it  is  necessary  to  attack  the  labyrinth 

•  Cases  10,  16,  23,  29,  32,  37,  49. 


INDICATIONS  FOR  OPERATION  65 

at  once,  because  we  are  unable  to  see  whether  the  labyrinth 
suppuration  is  inclined  to  produce  adhesions  or  to  set  up 
a  meningitis.  In  the  latter  event,  we  cannot  operate  any 
too  early.  Against  this  procedure  we  might  at  the  most  raise 
the  objection  that  perhaps  the  meningitis  might  be  caused 
by  the  operation.  A  glance  at  our  cases  is  sufficient  to  dis- 
pel this  doubt. 

Of  the  twenty  diffuse  purulent  manifest  labyrinthites* 
which  were  operated,  eight  died  and  twelve  were  cured.  Of 
those  who  died,  five  were  received  with  the  most  pronounced 
symptoms  of  meningitis  (unconscious,  or  with  purulent 
cerebrospinal  fluid),  one  died  of  cerebellar  abscess,  one  of 
pyaemia  with  thrombosis  of  the  cavernous  sinus,  and  only 
one  died  of  meningitis  which  did  not  exist  before  admission 
to  the  hospital.  This  case,  however,  in  particular,  justifies 
our  indication,  for  he  was  without  doubt  operated  too  late. 
Although,  even  on  the  day  after  the  radical  operation,  there 
appeared  nystagmus  to  the  healthy  side,  and  on  the  third 
day,  by  functional  testing,  the  purulent  labyrinthitis  was 
proven  beyond  doubt,  not  until  the  sixth  day,  when  the  lum- 
bar puncture  show^ed  turbid  cerebrospinal  fluid,  did  we 
succeed  in  getting  consent  to  perform  the  labyrinth  opera- 
tion. 

Here  we  must  report  that  in  one  case  (No.  52)  the  cere- 
brospinal fluid  at  the  time  of  operation  was  already  turbid, 
but  still  the  patient  was  saved  by  the  labyrinth  operation. 

Diffuse  Purulent  Latent  Labyrinthitis. 

Here  there  is  no  need  for  haste  with  the  operation,  but 
when  it  is  performed  we  can  only  conceive  of  the  radical 
and  the  labyrinth  operations  performed  at  one  time;  for 
the  labyrinthine  function  is  completely  destroyed  and  an 
eventual  extension  of  the  process  can  no  longer  be  recog- 
nized by  the  labyrinth  tests.  It  is  in  these  cases,  in  particu- 
lar, that  we  have  attained  the  best  results  with  the  laby- 

*Cases  51  to  70. 


66  DISEASES  OF  THE  LABYEIXTH 

rintli  operation.  We  have  only  to  recall  the  series  of  Zeroni 
and  those  of  our  ovra  cases,  which  vre  formerly  saw  die 
every  year  of  meningitis,  for  which  we  could  find  no  cause. 
To-day  we  have  no  longer  to  fear  the  sword  of  Damocles  in 
the  form  of  meningitis  which  hung  over  every  patient  in 
whom  a  radical  operation  was  necessary. 

Of  twenty-five  diffuse  purulent  latent  labyrinthites,  in 
which  the  labj^rinth  operation  was  performed,  twenty-one 
were  cured,*  four  died,  one  (No.  78)  in  consequence  of  an 
abscess  in  the  parietal  lobe,  one  (No.  81)  as  a  result  of  a 
meningitis  already  pronounced  before  the  operation  (puru- 
lent cerebro  spinal  fluid),  two  of  meningitis  which  was  not 
in  evidence  before  the  operation.  These  two  cases  are 
worthy  of  discussion.  The  one  (No.  74)  had  severe  head- 
ache before  the  operation  and  a  temperature  of  37.8°  C, 
but  we  could  ascribe  the  cause  to  a  tear  in  the  dura  made 
at  the  time  of  operation. 

The  other  case  (No.  71)  dates  back  to  the  year  1907 
and  belongs  more  to  our  experimental  series,  but  I  include 
it  because  it  presents  a  good  example  of  a  labyrinth  opera- 
tion performed  too  late.  The  functional  test  showed  con- 
versational voice  well  heard  by  the  speaking  tube  (the  ex- 
clusion apparatus  was  not  then  in  use),  caloric  reaction 
negative;  but,  on  the  other  hand,  the  turning  test  showed 
the  significant  difference  of  five  seconds  for  the  diseased 
side,  compared  with  thirty  seconds  for  the  healthy  ear ;  no 
fistula  symptom.  In  performing  the  radical  operation  there 
was  found  a  softening  of  the  bone  extending  into  the  laby- 
rinth nucleus,  and  yet  only  the  radical  operation  was  per- 
formed. The  very  next  day,  because  symptoms  of  a  begin- 
ning meningitis  were  recognized,  the  labyrinth  operation 
was  performed,  but  too  late. 

For  the  sake  of  a  better  grasp  of  the  indications  for 
operation,  we  will  arrange  them  in  a  table : 

•One  case  (Xo.  76)  died  shortly  after  admittance,  in  consequence  of  an 
abscess  in  the  parietal  lobe,  which  broke  into  the  ventricle  before  we  could 
operate.     This  case  was  not  included  in  these  twenty-five. 


OPERATIVE  TECHNIC 


67 


Circumscribed  Laby 
rintbitis : 


Diffuse  serous  second- 
ary labyrintbitis : 


Diffuse  purulent  mani- 
fest labyrinthitis : 

Diffuse   jourulent   la- 
tent labyrintbitis : 


First :  Eadical  operation. 

In  case  of  labyrinth  symptoms  and 
loss  of  function  after  the  radical 
operation:    Labyrinth  operation. 

(Labyrinth  operation  in  two  stages.) 

First :  Radical  operation. 

With  loss  of  function  after  the  radi- 
cal operation:  Labyrinth  opera- 
tion. 

(Labyrinth  operation  in  two  stages.) 

Radical  and  labyrinth  operation  at 
once. 

(Labyrinth  operation  in  one  stage.) 

Radical  and  labyrinth  operations 
together. 

(Labyrinth  operation  in  one  stage.) 


Fig.  17 


Technic  of  the  Labyrinth  Operation. 

The  credit  of  having  pointed  out  to  otology  the  way  to 
the  labvrinth  belongs  to  Jansen. 


68 


DISEASES  OF  THE  LABYRINTH 


The  metliod  wliich  I  rei^ularly  employ  is  essentially 
that  of  Neumann,  but  I  do  not  on  principle  go  as  far  as  the 
internal  meatus,  but  am  satisfied  with  the  opening  of  the 
vestibule  from  behind,  and  of  the  cochlea  from  in  front. 

I  proceed  in  the  following  manner : 

1.  The  typical  radical  operation. 

2.  Exposure  of  Trantmann's  triangle  (between  the  sinus, 
facial  ridge  and  middle  cranial  fossa),  (Fig.  17  shows  it 
in  a  case  with  the  sinus  extending  forward,  Fig.  18  with  the 
sinus  lying  well  backward.) 


The  pictures  are  made  entirely  after  preparations  belonging  to  the  author, 
also  Fig.  21,  which,  however,  was  already  printed  in  advance  in  V.  Urbant- 
achnitsch'g  text-book. 


Here  in  cases  in  which  the  sinus  lies  very  far  back  it 
is  not  always  necessary  to  expose  the  dura  {Frey  and  Ham- 
merschlag),  though  I  do  not  regard  its  exposure  as  a  dis- 
advantage nor  have  I  experienced  an}^  bad  consequences 
from  its  exposure.  In  the  cases  reported,  the  dura  was  in- 
deed torn  once,  but  out  of  so  many  eases  a  single  mishap 
cannot  count  for  much;  for  this  has  been  reported  by  nu- 


OPERATIVE  TECHXIC 


69 


meroiis  writers  even  in  the  radical  operation.  It  is  proper 
to  report  here  one  case  observed  bj*  myself,  in  which  three 
years  after  the  labyrinth  operation  there  appeared  a  men- 
ingocele. Thus  far  this  case  has  remained  the  only  tone 
reported. 


3.  Undermining  the  facial  ridge  and  the  horizontal  semi- 
circular canal.  In  so  doing  we  must  confine  ourselves  to 
the  area  behind  the  semicircular  canal  and  the  upper  third 
of  the  facial  ridge  (Fig.  19).  The  depth  to  which  we  must 
restrict  ourselves  in  the  process  of  undermining  amounts 
to  about  one  centimeter;  for  the  posterior  vestibular  wall, 
reckoned  from  the  prominence  of  the  horizontal  canal,  is 


70 


DISEASES  OF  THE  LABYRINTH 


on  the  average  between  nine  and  eleven  millimeters  thick. 
4.  During  the  chiseling,  we  introduce  from  time  to  time 
into  the  oval  window  my  very  pliable  labyrinth  probe  (Fig. 
20) #  If  this  is  freely  movable  behind  the  facial  ridge,  then 
the  vestibulum  is  already  opened  posteriorly  (Fig.  21). 


r 


Fig.  20 


Fig.  21 


5.  Opening  the  cochlea  from  the  front.  We  apply  the 
chisel  perpendicularly  in  front  of  and  as  close  as  possible 
to  the  facial  ridge,  and  remove  the  promontory  with  one 
blow.  (In  practice  on  the  cadaver,  it  is  advisable  to  place 
the  chisel  upon  the  subiculum  promontorii.)     (Fig.  22.) 

6.  Plastic  after  Pause. 

7.  Introduction  of  a  wick  drain  in  front  of  the  facial  ridge 
into  the  tympanic  cavity  and  another  behind  the  facial 
ridge. 

8.  The  usual  treatment  of  the  wound. 

The  dressing,  as  a  rule,  is  left  six  days.  If  severe  head- 
ache or  fever  appears,  the  dressing  must  be  changed  and 


OPERATIVE  TECHNIC  71 

the  woimd  examined,  in  order  that  retained  matter,  decom- 
posed secretion,  overlooked  bony  fragments,  etc.,  may  be 
properly  taken  care  of. 

In  general,  we  have  operated  in  the  manner  above  out- 
lined.   Only  in  a  few  individual  cases  from  external  causes 


/ 


Fig.  22 


(such  as  the  difficulty  of  the  operation,  lack  of  time  on  ac- 
count of  narcosis)  has  the  operator  preferred  the  method 
of  Hiusberg.  According  to  our  earlier  experiences,  it  would 
appear  that,  in  general,  under  this  method,  the  vertigo  and 
other  manifestations  of  a  reaction  disappear  later  than 


72 


DISEASES  OF  THE  LABYRINTH 


when  Neu7na}ni's  method  is  used  (see  also  V.  Urhant- 
schitsch's  text-book).  AVe  keep  the  patient  in  bed  from 
eight  to  ten  days  after  the  operation,  for  severe  vertigo 
seldom  continues  longer.  Alexander  prolongs  the  rest  in 
bed  as  long  as  six  weeks.  Generally  there  results  under 
this  operative  method  no  flow  of  cerebrospinal  fluid.     On 


Fig.  23 
Fig.  23  shows  the  completed  labyrinth  operation. 


the  eontrary,  if  we  go  as  deep  as  the  internal  meatus,  we 
must  expect  from  this  opening  a  flow  of  fluid  for  three  to 
five  days. 


TEEM  IX  AT  ION  73 

F.    TERMINATION 
Eegarding  the 

Circumscribed  Labyrinthitis 

we  know,  first  of  all,  that  a  fistula  may  exist  unchanged 
during  a  period  of  years.  In  Case  66  the  fistula  symptom 
could  be  produced  during  three  years.  After  the  radical 
operation  the  fistula  may  remain  a  long  time  without  pro- 
ducing any  symptoms,  or,  at  the  most,  veiy  slight  symp- 
toms ;  for  the  retention  of  pus,  always  giving  rise  to  severe 
attacks  of  vertigo,  drains  into  the  antrum  or  the  middle 
ear.  At  the  present  time  I  have  under  treatment  a  private 
case  in  whom  I  diagnosed  a  large,  dry  cholesteatoma  more 
than  a  year  ago.  This  had  destroyed  the  attic  and  antrum 
wall  and  posterior  meatal  wall,  and,  as  demonstrated  by 
the  probe  and  by  the  Roentgen  findings,  had  partially  de- 
stroyed the  mastoid.  In  short,  it  is  a  perfect  picture  of  a 
radical  operation  performed  by  nature,  yet  with  preserva- 
tion of  the  drum  memhrane, excepting  ShrapnelVs  membrane. 
The  head  of  the  hammer  and  the  body  of  the  incus  are  ab- 
sent. The  fistula  symptom  was  very  pronounced.  The  pa- 
tient objected  very  strongly  to  an  operation,  so  that  I  de- 
cided to  remove  the  cholesteatoma  with  a  curved  curette. 
This  I  did  in  several  sittings  through  the  external  meatus, 
through  which  I  could  go  with  a  sharp  spoon  well  into  the 
depths  of  the  mastoid.  After  cleaning  out  the  cholestea- 
toma, the  frequent  attacks  of  vertigo  spontaneously  ceased, 
especially  those  attacks  produced  by  movements  of  the 
head.  The  patient  is  to-day  still  entirely  free  from  sub- 
jective symptoms,  though  the  fistula  symptom  is  bi'pically 
present,  and,  besides,  we  can  now  see  quite  plainly  the  epi- 
dermized  prominence  of  the  lateral  semicircular  canal 
(cholesteatoma  matrix),  in  which  one  point  shines  through 
somewhat  darker.  If  this  spot  is  touched  with  a  probe,  the 
patient  has  a  typical  fistula  symptom  accompanied  with 
severe  vertigo. 
The  fistula  may,  however,  heal  completely,  either  with  con- 


74  DISEASES  OF  THE  LABYRINTH 

nective  tissue  (Case  19)  or,  indeed,  with  a  bony  formation 
(Case  1). 

Frequently  (fifteen  times  in  thirty-two  cases)  the  cir- 
cumscribed labyrinthitis  develops  into  a  diffuse  serous  sec- 
ondary labyrinthitis.  But  this  is  in  itself  usually  not  dan- 
gerous, though  it  may  develop  into  a  purulent  labyrinthitis, 
and  this  is  to  be  regarded  as  dangerous  only  through  being 
the  connecting  link  between  a  circumscribed  labyrinthitis 
and  a  meningitis.  On  the  other  hand,  a  diffuse  serous  sec- 
ondary labyrinthitis  frequently  affects  seriously  the  func- 
tion of  the  labyrinth.  There  may  be  marked  diminution  of 
the  sense  of  hearing  or  even  complete  loss  of  hearing  in  the 
affected  ear,  with  sometimes  loss  of  the  caloric  and  turning 
reactions. 

In  a  case  of  E.  U  rh  ants  chit  sch,  in  which  the  fistula  was 
healed  by  connective  tissue,  there  was  a  recurrence  after 
three  years,  with  bulging  of  the  membrane,  which  closed 
the  fistula,  and  a  reappearance  of  the  fistula  symptom. 

Diffuse  Serous  Secondary  Lohyriiithitis. 

This  can  undoubtedly  heal  spontaneously  either  without 
loss  of  function  or  with  loss  of  hearing  and  sometimes  with 
loss  of  the  caloric  and  turning  reactions.  In  this  last  case 
it  is  no  longer  to  be  differentiated  from  a  diffuse  purulent 
latent  labyrinthitis.  Rarely  it  may  also  be  directly  trans- 
formed into  a  purulent  labyrinthitis  (Case  19*).  The  prog- 
nosis is,  therefore,  on  the  whole,  good.  Of  our  twelve  cases, 
four  died,  though  two  of  these  were  of  temporal  lobe 
abscess  (Nos.  22  and  29).  One  died  of  meningitis,  prob- 
ably not  caused  by  the  labyrinth  (No.  29) ;  and  in  one  (No. 
33)  we  have  laid  the  blame  for  the  meningitis  upon  the  laby- 
rinth operation,  which  was  not  absolutely  indicated. 

Diffuse  Purulent  Manifest  Labyrinthitis. 

Of  all  the  labyrinth  diseases,  this  presents  the  very  worst 
prognosis  for  the  life  of  the  patient. 

*  We  must  imagine  that  as  a  matter  of  fact  more  often  a  diffuse  purulent 
latent  labyrinthitis  develops  from  a  circumscribed  form,  going  intermediately 
through  the  form  of  a  diffuse  serous  second^iry  labyrinthitis. 


TERMINATION  75 

Of  twenty  cases,  eight  died,  thoiigli  we  can  look  upon  only 
six  of  these  cases  as  resulting  directly  from  the  labyrinthi- 
tis. For  these  six  died  of  meningitis.  Of  the  other  two, 
one  died  of  meningitis  and  thrombosis  of  the  cavernous 
sinus,  the  former  probably  proceeding  from  the  latter ;  the 
other,  of  a  cerebellar  abscess. 

The  labyrinth  operation  is  surely  a  life-saving  measure, 
for  of  the  twenty  cases,  twelve  were  cured,  among  them  one 
with  turbid  cerebrospinal  fluid.  Of  the  cases  which  died, 
five  upon  admission  to  the  hospital  already  had  symptoms 
of  meningitis,  one  was  operated  late,  as  has  already  been 
stated  (No.  56). 

It  is  noteworthy  that  the  labyrinth  suppurations  originat- 
ing in  acute  otitis  apparently  led  to  an  early  meningitis,  in- 
asmuch as  all  four  cases  were  brought  in  with  a  meningitis 
already  present.  This  corresponds  with  the  experience  of 
other  authors  {Sclieihe,  Wanner)  regarding  the  danger  in 
labyrinthitis  originating  in  acute  otitis. 

Diffuse  Purulent  Latent  Labyrinthitis. 

Here  naturally  the  end  result  may  be  complete  healing, 
with  organization  of  the  exudate  or  of  the  granulations. 
Indeed,  it  may  result  in  complete  bony  destruction  of  the 
diseased  labyrinth.  Politzer  has  described  such  a  case,  as 
is  well  known.  Eecently  I  operated  a  case  in  which  I  found 
a  similar  condition.  There  was  absolutely  no  semicircular 
canal  to  be  found,  the  probe  could  be  introduced  a  short  dis- 
tance into  the  oval  window,  but  soon  ipet  with  a  bony  re- 
sistance. On  removing  the  promontory,  there  was  found 
no  cavity,  only  bone. 

But,  as  a  rule,  the  disease  extends  slowly  and  steadily  to- 
ward the  cranial  cavity,  and  finally  results  in  some  compli- 
cation, most  frequently  in  a  cerebellar  abscess  and  menin- 
gitis. Earely  it  extends  through  the  upper  semicircular 
canal,  resulting  in  a  temporal  lobe  abscess,  unless  the  dis- 
eased focus  is  removed  by  a  labyrinth  operation.  The  rad- 
ical operation,  as  we  have  already  stated  at  full  length, 


76  DISEASES  OF  THE  LABYRINTH 

maj'  only  hasten  the  meningitis,  for  it  does  not  remove  the 
focus  of  pus,  but,  by  the  traumatism  involved,  may  cause 
irritation,  as  Brieger  has  observed. 

Of  twenty-six  cases,  twenty-one  were  cured;  three  died 
of  meningitis,  two  of  temporal  lobe  abscess.  In  the  last  two 
cases  the  labyrinth  suppuration  apparently  was  not  the 
cause  of  the  abscess.  Of  the  oases  of  meningitis,  one  was 
caused  by  a  tear  in  tlie  dura,  the  two  others  plainly  origi- 
nated in  the  labyrinth.  The  one  case  (No.  71),  as  we  have 
already  clearly  shown,  was  operated  too  late ;  the  other  had 
a  meningitis  before  the  operation.  We  see  that  the  prog- 
nosis in  a  diffuse  purulent  latent  labyrinthitis,  when  the 
labyrinth  operation  is  performed  sufficiently  early,  is 
very  good. 


CHAPTER  III 
INJURIES  OF  THE  LABYRINTH 

As  a  rule,  an  operative  injury  of  the  labyrinth  is  recog- 
nized by  the  immediate  appearance  upon  awakening  from 
the  anaesthetic  of  symptoms  of  a  diffuse  labyrinthitis,  i.e. 
marked  rotatory  nystagmus  of  the  third  degree  to  the 
healthy  side,  vertigo,  emesis  and  disturbances  of  equilib- 
rium; and  the  patient  is  deaf  or  nearly  deaf  on  the  oper- 
ated side.  (If  the  promptness  of  the  appearance  of  these 
sjTuptoms  is  not  always  clearly  expressed  in  case  his- 
tories 105  to  108,  it  is  because  sometimes  the  patients  were 
not  always  examined  immediately  after  awaking  from  the 
anaesthetic,  and  vertigo  and  emesis  w^ere  ascribed  by  both 
the  patient  and  the  attendant  to  the  an-aesthetic.) 

Traumatic  injuiy  of  the  labyrinth  naturally  does  not  con- 
stitute any  reason  for  at  once  further  opening  the  laby- 
rinth, whether  we  have  a  luxation  of  the  stapes  or  an  in- 
jury of  the  semicircular  canal  or  of  the  promontory.  On 
the  contrary',  with  the  relative  mildness  which  character- 
izes these  injuries,  according  to  various  observations,  and 
particularly  after  a  fine  pathological-anatomical  study  of 
Goerke,  our  chief  duty  after  such  injuries  consists  in  the 
most  careful  observation  of  the  patient.  As  a  rule,  the 
nystagmus  and  the  accompanying  symptoms  disappear 
within  a  few  days,  and  the  injury  gives  rise  to  no  further 
results.  In  our  cases  the  labyrinth  symptoms  lasted  ten 
days  in  Case  105,  fourteen  days  in  Case  106,  eight  days  in 
Case  107  and  six  days  in  Case  108. 

As  regards  the  nystagmus,  injuries  of  the  labyrinth  do 
not  give  symptoms  that  are  always  the  same.  Theoreti- 
cally, immediately  after  awakening  from  the  anaesthetic 
there  should  be  a  marked  rotatory  nystagmus  toward  the 
healthy  side;  for  the  opening  of  the  labyrinth  is  accom- 

77 


78  DISEASES  OF  THE  LABYEINTH 

panied  by  a  loss  of  fluid,  if  only  perilymph,  which  would 
also  probably  cause  a  complete  temj^orary  arrest  of  func- 
tion of  the  wounded  ear. 

This  behavior  was  also  present  in  Cases  106,  107  and  108. 
In  Case  105,  on  the  contrary,  there  were  present  (though 
not  observed  until  the  next  day),  besides  attacks  of  nystag- 
mus toward  the  healthy  side,  also  a  slow  rolling  of  the  eyes 
with  a  horizontal  movement  to  and  fro. 

This  atypical  behavior  is  perhaps  to  be  ascribed  to  a  cir- 
cumscribed labyrinthitis  setting  in  early.  The  assumption 
that  a  circumscribed  labyrinthitis  may  have  its  origin  in 
a  traumatism  of  the  labyrinth  seems  reasonable,  when  we 
consider  that  after  an  injury  of  the  labyrinth  there  may 
be  for  months  attacks  of  vertigo  of  the  type  which  char- 
acterize a  circumscribed  labyrinthitis;  that  is,  provoked 
by  movements  of  the  head,  severe  muscular  efforts,  etc.  In 
this  connection,  a  case  of  KummeVs  is  very  instructive. 
In  this  case,  after  an  operation  on  the  nose,  there  followed 
an  acute  otitis  with  finally  a  mastoiditis  on  the  right  side. 
An  antrotomy  was  performed  on  May  12,  1903,  when  the 
horizontal  semicircular  canal  was  injured.  Immediately 
there  was  severe  vertigo  and  marked  horizontal  nystagmus 
to  the  left.  Five  days  later  there  is  noted  in  the  case  his- 
tory, ''The  nystagmus  disappears  in  a  few  days."  Then, 
''until  the  close  of  1903  there  were  often  severe  attacks  of 
vertigo,  particularly  after  physical  effort,  but  also  during 
ordinary  work  about  the  house.  These  entirely  disap- 
peared by  the  end  of  the  following  May,  but  some  uncer- 
tainty of  variable  degree  occurs  upon  physical  strain,  that 
is,  upon  suddenly  turning  in  a  direction  contrary  to  the 
movement  of  the  hands  of  the  clock. "  ' 

In  the  beginning  of  1904  Kiimmel  saw  the  patient  again, 
and  observed  total  deafness  in  the  injured  ear  (tested  ac- 
cording to  the  principles  of  Bezold*). 

In  Case  105  the  hearing  was  not  tested  after  the  injury; 

•  Concerning  Infectious  Labyrinth  Diseases,  Arch.  f.  Klin.  Med.  Vol.  55  u. 
Ref.  Hinsberg,  Z.  f.  O.  Vol.  51,  page  311. 


INJURIES  OF  THE  LABYRINTH  79 

in  Case  106  it  was  practically  zero  before  the  operation; 
in  Case  107  it  diminished  from  three  and  a  half  meters  for 
the  spoken  voice  (tested  with  the  exclusion  apparatus)  so 
that  the  patient,  on  the  following  day,  could  only  hear 
words  spoken  at  the  external  ear.  In  Case  108  it  fell  from 
one  meter  for  the  spoken  voice  (examined  with  the  exclu- 
sion apparatus)  to  one-quarter  meter,  and  remained  there 
until  the  appearance  of  a  purulent  labyrinthitis,  nine  days 
later,  which  totally  destroj^ed  the  hearing. 

In  KiimmeVs  case  deafness  also  occurred,  though  later. 
On  the  other  hand,  this  did  not  occur  in  a  single  case  of 
BezoUVs  nor  in  Neumann's  case.  In  the  last  case  the  hear- 
ing was  completely  restored. 

In  general,  we  may,  therefore,  expect  a  diminution  of 
hearing  immediately  after  an  injury  of  the  labyrinth, 
amounting  to  deafness  for  the  spoken  voice,  or  to  a  percep- 
tion of  a  loud  voice  close  to  the  ear,  in  favorable  cases  even 
one-fourth  meter  for  the  conversational  voice. 

Just  how  the  hearing  will  behave,  naturally,  depends 
upon  the  pathological  changes  which  take  place.  In  a  sim- 
ple closure  of  the  supposed  opening  by  a  callus  or  con- 
nective tissue  formation  without  severe  inflammatory 
symi^toms,  as  we  may  assume  them  to  be  formed  histologi- 
cally, according  to  the  investigations  of  Marx*  there  is 
possible  an  almost  complete  restoration  of  hearing,  as  in 
Neumann's  case,  for  example. 

But  since  the  injury  jDractically  always  occurs  in  operat- 
ing for  purulent  middle  ear  disease,  as  a  rule,  it  is  hardly 
likely  that  it  would  run  its  course  in  the  labyrinth  without 
inflammatory  symptoms,  even  though  they  are  not  always 
those  dependent  upon  a  purulent  condition.  For  this  rea- 
son we  have  in  the  majority  of  cases  the  permanent  and 
severe  damage  to  the  hearing.  Indeed,  the  infection  may 
also  come  later,  as  undoubtedly  is  shown  by  Case  108.  In 
this  case  the  injury  of  the  labyrinth  produced  marked  ves- 

*  Concerning  Labyrinthitis  in  Acute  Middle  Ear  Suppuration,  Z.  f.  O.  Bd. 
60,  3  &  4  H.,  page  221. 


80  DISEASES  OF  THE  LABYEIXTH 

tibular  symptoms  with  diminution  of  hearing  from  one 
meter  to  one- fourth  meter  for  the  conversation  voice,  but 
nine  days  later  there  followed  a  sudden  labyrinth  suppura- 
tion which  entirely  destroyed  the  hearing. 

Nor  is  it  immaterial  where  the  traumatism  is  localized. 
In  injury  of  the  oval  window  (stapes  luxation)  only  the  peri- 
lymphatic space  is  opened;  whereas,  in  the  horizontal 
semicircular  canal,  should  a  section  be  cut  away  (as  in 
Neumann's  case),  the  membranous  semicircular  canal  and 
the  endolymphatic  space  are  both  opened  at  the  same  time. 

The  immediate  effect,  according  to  our  conception,*  must 
be  the  same  for  the  hearing;  whereas,  in  case  of  an  infec- 
tion, injury  of  the  semicircular  canal  offers  fewer  chances 
for  the  extension  of  the  suppuration  than  does  the  opening 
of  the  oval  window. 

The  caloric  test  was  not  made  in  Case  105 ;  in  Case  106 
the  caloric  reaction  was  lost;  in  Cases  107  and  108,  as  well 
as  in  Neumann's  case,  it  remained  present.  It  would  seem 
that  it  is  more  likely  to  be  preserved  than  to  be  destroyed. 
The  turning  test  was  made  in  Case  107,  and  was  present 
likewise  in  Neumann's  case. 

Practically  the  most  important  feature  is  the  onset  of 
vestibular  symptoms  immediately  after  the  operation,  w^hile 
the  serous  labyrinthitis,  which  alone  has  to  be  considered 
in  the  differential  diagnosis,  appears,  according  to  our  ex- 
perience, at  the  earliest,  twelve  hours  after  operation. 

Of  further  importance  is  the  question  as  to  whether  or 
not  a  labyrinth  injury  is  followed  by  infection.  This  can 
only  be  answered  by  the  course  of  the  symptoms.  In  a  non- 
infected  labyrinth  injury,  the  manifestations  continuously 
diminish  from  the  day  of  operation  during  the  succeeding 
days ;  in  an  infected  injury  of  the  labyrinth,  the  symptoms 
reach  a  second  period  of  intense  severity,  or  recur  sud- 
denly after  they  have  run  their  course.    A  classic  example 

*  Ruttin:  Contributions  to  the  Pathology  of  Deafmutism,  together  with 
Observations  on  the  Physiology  and  Pathology  of  the  Peri-  and  Endolymph. 
Transactions  of  the  German  Otological   Society,  Dresden,   1910. 


STATISTICS  81 

of  this  last  possibility  is  afforded  by  our  Case  No.  108. 
After  practically  all  vestibular  symptoms  had  disappeared, 
the  symptoms  suddenly  returned  with  renewed  severity, 
with  complete  loss  of  the  labyrinth  function.  The  nystag- 
mus in  this  case  is  hardly  to  be  explained  as  of  labyrinth- 
ine origin ;  it  is  far  more  likely  to  be  explained  by  a  begin- 
ning disease  of  the  posterior  cranial  fossa  (serous  menin- 
gitis) ;  for,  with  a  complete  loss  of  function  on  the  part 
of  the  labyrinth,  the  marked  nystagmus  was  directed  to- 
ward the  diseased  side. 

We  must  explicitly  state  that  the  fever  gives  us  no  point 
for  the  differential  diagnosis  between  simple  trauma  of  the 
labyrinth  without  subsequent  infection  and  injury  of  the 
labyrinth  with  later  infection. 

.    G.    STATISTICS 

Cured 
83 


not  operated       radical  operation  rad.  op.— later  labyr.  op.  labyr.  op. 

7  38  4  34 

Died 
25 

not  operated       radical  operation  rad.  op.— later  labyr.  op.  labyr.  op. 

1  5  7  12 


pur.  men.    other  causes    pur.  men.    other  causes    pur.  men.   other  causes    pur.  men.   other  causes 
0  1  0  5*)  3  4t    )  9  3t    ) 


arising  arising  arising  arising  arising  arising 

before  after  before  after  before  after 

op.               op.                op.  op.  op.  op. 

0              0               0  3  8  1 

Note:     rad.  op.  =  radical   operation;    men.  =  meningitis ;    pur.  =  purulent. 

Even  if  we  do  not  attach  too  high  a  value  to  the  statis- 
tics, we  must  at  least,  from  the  relatively  large  number  of 
observed  cases  and  from  the  manner  of  their  grouping,  ex- 

*  Two  of  phthisis,  one  unknown  cause,  no  post  mortem,  two  abscesses  of  tlie 
temporal  lobe. 

tThree  of  cerebellar  abscess,  one  of  cavernous  sinus  thrombosis. 

JOne  of  carcinoma,  two  of  temporal  lobe  abscess. 


82  DISEASES  OF  THE  LABYRINTH 

pect  some  W^hi  upon  the  question  as  to  tlie  danp^er  of  opera- 
tive procedures  in  diseases  of  the  labyrinth.  Eighty-three 
cured  eases  stand  in  contrast  with  twenty-five  fatal  cases. 
Of  the  eighty-three  cured  cases,  seven  were  not  operated, 
thirty-eight  had  the  radical  operation,  and  thirty-eight  the 
labyrinth  operation;  four  in  one  stage  and  thirty-four  in 
two  stages.  Of  the  twenty-five  fatal  cases,  one  died  of  tu- 
berculosis without  operation,  five  had  the  radical  opera- 
tion, of  whom  none  died  of  a  meningitis  of  labyrinthine 
origin  (the  doubtful  case,  No.  43,  we  must  leave  out). 
Seven  had  the  labyrinth  operation  in  two  stages,  of  whom 
only  three  died  of  a  meningitis  of  labyrinthine  origin.  All 
three  cases  (Nos.  56,  71,  101)  presented  labyrinth  symp- 
toms only  after  the  radical  operation;  in  two  cases  (Nos. 
56  and  71)  there  is  no  doubt  that,  according  to  our  indi- 
cations for  operating,  the  labyrinth  operation  was  decided 
upon  too  late.  Only  Case  101  was  operated  promptly,  but 
nevertheless  died.  Twelve  fatal  cases  were  operated  upon 
in  one  stage,  of  whom  three  died  of  other  causes,  and  nine 
of  meningitis  of  labyrinthine  origin.  Of  these  nine  cases, 
eight  had  well-defined  clinical  sjinptoms  of  a  meningitis 
before  the  operation,  with  purulent  cerebrospinal  fluid. 
Only  in  one  case  (No.  33)  could  the  meningitis  of  labyrinth- 
ine origin  be  said  to  have  been  caused  by  the  labyrinth 
operation,  inasmuch  as  the  patient  showed  no  evi- 
dence of  meningitis  before  the  operation;  for  the  men- 
ingitis appeared  not  until  five  days  after  the  labyrinth 
operation. 

And  in  this  very  case  our  indications  for  operating  were 
not  strictly  observed,  inasmuch  as  the  caloric  reaction  was 
still  present. 

Now  let  us  look  at  our  figures  from  another  point  of  view. 
In  all,  just  one  hundred  cases  of  labyrinth  diseases  were 
operated. 

In  forty-three  the  radical  operation  was  performed. 

In  eleven  the  labyrinth  operation  in  two  stages  was  per- 
formed; that  is,  first  the  radical,  and  later  the  labyrinth. 


STATISTICS  83 

In  forty-six  the  radical  and  labyrinth  operations  were 
performed  at  the  same  time. 

Of  the  forty-three  having  only  the  radical  operation,  none 
died  of  a  meningitis  of  labyrinthine  origin.  These  cases 
were  decidedly  circumscribed  and  not  purulent  diffuse  laby- 
riuthites;  in  short,  cases  in  which  the  labyrinth  function 
was  not  blotted  out.  Therefore,  we  may  conclude  that  the 
radical  operation  is  not  dangerous  in  these  cases.  Of  the 
eleven  cases  operated  in  two  stages,  three  died  of  menin- 
gitis of  labyrinthine  origin  which  appeared  after  the  radical 
operation.  Before  the  operation  all  three  had  no  positive 
symptom  of  labyrinthine  disease;  they  belong,  therefore, 
in  the  group  of  post-operative  labyrinthitis,  since,  without 
doubt,  in  two  of  these  cases  the  labyrinth  operation  came 
too  late;  this  is  the  more  significant  when  we  compare  them 
with  Cases  64  and  108,  in  which  the  labyrinth  operation  was 
performed  in  time  and  the  patients  were  saved.* 

Considering  in  comparison  the  forty-six  cases  which  were 
operated  in  one  stage,  we  see  that  nine  died  of  a  meningitis 
of  labyrinthine  origin.  Of  the  nine,  eight  had  a  meningitis 
1)efore  the  operation,  and  only  one  developed  it  after  the 
labyrinth  operation.  The  majority  of  these  cases  were 
diffuse  purulent  labyrinthites.  The  large  proportion  of 
meningitis  cases  which  these  labyrinthites  present  proves 
their  dangerous  character  in  and  for  themselves.  The  cir- 
cumstances that  only  a  single  fatal  case  (and  that  one  truly 
not  properly  belonging  in  this  group  and  operated  without 
justifiable  indications)  may  be  laid  at  the  door  of  the  laby- 
rinth operation,  while  out  of  thirty-four  cases  operated  in 
one  stage  at  the  proper  time  with  all  indications  for  oper- 
ating present,  not  a  single  case  ending  fatally — these  cir- 
cumstances show  best  of  all  what  an  active  procedure  upon 
the  labyrinth  can  accomplish,  assuming  careful  observance 
of  all  the  indications  and  proper  operative  technic. 

According  to  these  figures  the  mortality  may  be  said  to 

*  Compare  also  a  case  of  mine  previously  reported  by  Neumann.    Austrian 
Otol.  Society,  1907. 


84  DISEASES  OF  THE  LABYRINTH 

be  2.2  per  cent.  Neumann  had  seven  deaths  out  of  twenty- 
seven  labyrinth  operations,  but  not  caused  by  the  opera- 
tion. Freitag,  from  the  literature,  estimates  the  mortality 
at  4.5  per  cent,  for  the  labyrinth  operation,  but  gives  the 
mortality  of  the  Breslau  clinic,  according  to  the  reports  of 
Hinsberg,  as  zero.  By  comparison,  Freitag  finds  that  the 
figures  for  non-operated  eases  of  labyrinth  suppuration  to 
be,  for  Jansen,  10  per  cent.;  for  Whitehead,  33  per  cent.; 
for  Friedrich,  50  per  cent. ;  for  Gerher,  16.6  per  cent. 

Naturally  we  cannot  expect  that  the  labyrinth  operation 
is  capable  of  saving  hopeless  cases  of  meningitis,  such  as 
the  eight  cases  in  which  there  was  present  a  meningitis  be- 
fore the  operation. 

Even  if  in  such  cases  we  still  advise  operation  (for,  with- 
out it,  the  fight  is  absolutely  lost),  it  sometimes  happens 
that  the  courageous  operator  gets  a  remarkable  result,  by 
way  of  an  unexpected  cure,  which  compensates  him  for  the 
trouble  and  disappointment  of  operations  performed  in 
vain. 


CHAPTER  IV 
SEROUS  INDUCED  LABYRINTHITIS 

Alexander  called  attention  to  the  fact  that  nonpurulent 
(serous)  inflammations  of  the  labyrinth  sometimes  occur 
with  violent  labyrinth  symptoms. 

For  a  comprehension  of  this  disease  it  is  necessary  to 
separate  the  ''serous  labyrinthitis,"  originating  in  a  fistula 
and  known  as  a  diffuse  serous  secondary  form,  from  the 
** induced  labyrinthitis,"*  which  proceeds  directly  through 
the  labyrinth  wall. 

The  first  is  only  a  stage  in  the  slow  advancement  of  the 
suppuration  from  the  tympanic  cavity  upon  the  labyrinth. 
But  the  last  is  a  suddenly  appearing  nonpurulent  inflam- 
mation of  the  labyrinth — perhaps  often  only  a  collateral 
(concomitant)  oedema  of  the  labyrinth. 

It  may  occur : 

1.  In  the  course  of  acute  otitis. 

2.  In  the  course  of  chronic  otitis. 

3.  In  cases  of  unhealed  radical  operation. 

4.  A  short  time  after  the  radical  operation. 

Of  our  eleven  cases,  there  belonged : 

To  the  first  group,  no  case; 

To  the  second  group,  no  case; 

To  the  third  group,  four  cases; 

To  the  fourth  group,  seven  cases. 

Cases  of  the  first  group  we  have  certainly  observed,  but 
we  have  no  case  records  of  such,  for  the  acute  otites  which 
we  receive  at  the  clinic  as  bed  patients  arrive  in  too  ad- 

*  Ruttin;  Concerning  the  Question  of  an  Ectasia  of  the  Ductus  Cochlearis. 
Transactions  of  the  German  Otological  Society,  Heidelberg,  1908. 

85 


86  DISEASES  OF  TEE  LABYRINTH 

vanced  a  stage.*  But  Voss  lias  reported  a  series  of  such 
cases.  The  picture  is,  on  the  whole,  the  same,  whether  the 
serous  induced  labyrinthitis  grows  directly  out  of  an  acute 
otitis  or  out  of  a  chronic  otitis.  The  symptoms  are  en- 
tirely those  of  the  diffuse  purulent  manifest  labyrinthitis : 
marked  rotatory  nystagmus  to  the  healthy  side,  vertigo, 
emesis,  disturbances  of  equilibrium  and  impairment  of 
hearing,  and  even  absence  of  hearing.  The  complete  clin- 
ical picture  often  appears  suddenly,  without  any  reference 
in  the  history  to  vertigo. 

The  differentiation  from  the  diffuse  purulent  manifest 
form,  when  it  is  at  all  possible  to  make  it  with,  certainty, 
is  made  by  the  functional  test.  As  long  as  a  remnant  of 
functional  activity  of  the  labyrinth  (hearing,  caloric  and 
turning  reactions)  can  be  demonstrated,  so  long  must  we 
assume  that  we  are  dealing  with  a  disease  not  yet  of  the 
purulent  diffuse  form,  that  is,  with  a  serous  induced 
labyrinthitis. 

We  already  know  from  the  cases  of  Voss  that  undoubt- 
edly such  a  serous  induced  labyrinthitis  may  proceed  with 
complete  loss  of  function.  It  seems,  on  comparing  our  cases 
with  those  of  Voss,  that  the  serous  induced  labyrinthitis 
is  more  frequent  among  the  labyrinthites  following  an  acute 
otitis  than  among  those  occurring  in  the  course  of  a  chronic 
middle  ear  suppuration  or  after  the  radical  operation. 

It  is  quite  possible  for  a  purulent  inflammation  of  the 
labyrinth  to  occur  without  any  breaking  through  of  the 
labyrinth  wall,  in  consequence  of  a  transmigration  of  bac- 
teria through  the  annular  ligament  or  through  the  round 
window\    Substantiating  the  first  possibility,  we  have  the 


•  Since  completing  the  manuscript  for  this  book  I  have  reported  (Austrian 
Otol.  Soc.,  1911)  a  case  of  particular  interest  which  belongs  in  this  series. 
Simultaneously  with  the  otitis,  which  was  still  in  the  serous  stage,  there 
appeared  a  very  severe  serous  labyrinthitis.  Here  belong  also  the  observa- 
tions of  Alt  and  Politzer  (vide  Politzer's  Text-book).  Of  interest  is  also  the 
report  of  Otto  Meyer,  to  the  effect  that  a  serous  labyrinthitis  may  also  arise 
haeraatogenetically.  In  the  case  reported  by  him  there  was  simultaneously 
with  a  purulent  otitis  and  meningitis,  a  serofibrinous  labyrinthitis  produced 
by  an  accumulation  of  cocci  in  the  blood  vessels  of  the  labyrinth. 


SEEOUS  INDUCED  LABYRINTHITIS  87 

investigations  of  Gruenhergf  the  second  possible  path  is 
substantiated  by  the  findings  of  0.  Meyer  and  XJffenorde.\ 

To  the  labyrinth  suppuration  arising  in  the  course  of 
an  acute  otitis,  we  must  ascribe  a  special  seriousness,  a 
special  tendency  to  meningitis.  The  question,  therefore, 
arises:  Shall  we  open  the  labyrinth,  or  not,  in  a  diffuse 
labyrinthitis  with  complete  loss  of  function!  For  we  do 
not  yet  know  if  we  are  dealing  with  a  purulent  or  only  with 
a  serous  labyrinthitis.  Unfortunately,  the  number  of  cases 
observed  is  not  yet  sufficiently  great;  but  we  would  per- 
sonally advise  waiting  to  see  if  the  sjrmptoms  increase  or 
decrease  in  severity,  keeping  the  patient  under  the  closest 
scrutiny.  As  a  rule,  a  labyrinthitis  arising  in  the  course 
of  an  acute  otitis  appears  to  be  only  serous. 

That  even  a  labyrinth  suppuration  arising  in  the  course 
of  an  acute  otitis  may  heal  spontaneously  is  proved  by  the 
carefully  observed  case  of  Marx^  and  the  panotitis  of 
Politzer.  In  fact,  the  possibility  of  a  spontaneous  cure  of 
purulent  mastoiditis  is  not  to  be  denied,  yet  no  otologist 
would  in  these  days  wait  for  this  eventuality. 

Further,  we  do  not  often  see  cases  of  the  second  group 
in  their  most  acute  stage,  for  the  duration  of  the  dis- 
turbance is  short.  But  we  do,  without  doubt,  see  many 
cases  which  are  to  be  interpreted  as  cases  of  induced  serous 
labyrinthitis  which  have  run  their  course.  These  constitute 
a  large  number  of  those  chronic  suppurations  in  the  course 
of  which  the  patients  become  deaf  without  having  lost  the 
vestibular  reaction.  The  histological  demonstration  of 
such  cases  of  serous  labyrinthitis  which  have  run  their 
course  is  to  be  sought  in  the  cases  of  Herzog  and  in  the 
cholesteatoma  deafness  of  Siebenmann-Nager.  The  rela- 
tive frequency  of  the  third,  and  particularly  of  the  fourth, 
group  is  striking.    The  third  group  can  be  explained  by  the 

*  Griinherg:     Contributions   to   the   Knowledge  of  Labyrinth  Diseases   II, 
Zeitschrift  f.  O.  Bd.  58,  1909. 

fUffcnorde:    Transact.  German  Otol.  Soc,  Dresden,  1910. 

tilarx,  Zeitschrift  f.  Otology,  Bd.  LX,  H  and  4. 


88  DISEASES  OF  THE  LABYRINTH 

fact  that  in  unhealed  radical  operations  we  are  doubtless 
often  dealing  with  migratory  labyrinth  diseases,  which,  in- 
vading the  labyrinth  more  or  less  deeply,  sooner  or  later 
lead  to  a  clinical  labyrinthine  inflammation. 

Thus  are  to  be  explained  the  undoubtedly  correct  find- 
ings of  Alexander,  to  the  effect  that  after  radical  opera- 
tions deafness  of  the  affected  ear  often  follows. 

Here  is  to  be  mentioned  a  case  of  Wojatscheks*  in  which, 
seven  weeks  after  the  operation  for  an  acute  mastoiditis, 
there  developed  a  serous  labyrinthitis  with  loss  of  hearing 
and  of  the  caloric  reaction.  Two  weeks  later  the  labyrinth 
function  was  again  almost  fully  restored. 

Still  more  interesting  is  the  case  of  Herzfeld.\ 

In  an  acute  otitis,  fourteen  days  after  the  onset,  the  mas- 
toid was  opened.  Because  of  pains,  oedema  over  the 
zygoma,  diminution  of  hearing  to  the  perception  of  the 
whispered  voice  only  at  the  meatus,  and  horizontal  nystag- 
mus to  the  diseased  side,  the  radical  operation  was  per- 
formed twelve  days  later.  Twenty-six  days  later  there  oc- 
curred vertigo,  emesis,  small  intermittent  pulse,  tremor  of 
the  entire  body,  nystagmus  on  looking  straight  forward 
and  to  both  sides,  and  complete  deafness  of  the  right  side. 
On  account  of  the  severe  symptoms,  the  labyrinth  was 
opened  the  next  day,  but  nothing  of  a  pathological  nature 
was  found  either  in  the  vestibulum  or  in  the  cochlea.  How- 
ever, the  labyrinth  symptoms  disappeared. 

We  can  hardly  wonder  at  the  frequent  occurrence  of 
cases  of  the  fourth  group  when  we  realize  that  the  radical 
operation  undoubtedly  means  more  or  less  traumatism  for 
the  labyrinth  wall,  following  which  it  is  natural  that  there 
should  be  a  severe  reaction  inflammation.  With  its  rela- 
tive closeness,  the  labyrinth  can  very  easily  be  within  the 
area  of  this  inflammation. 

•  Russian  Monatschr.  f.  0.  1909,  ref.  Z.  f.  O.  Bd,  60. 

fHerzfcJd:  Presentation  of  a  man  with  but  one  labyrinth.  Report  of 
the  meeting  of  the  Berlin  Otolog.  Soc,  Nov.  5,  1909,  reported  by  Claus,  Z.  f. 
O.   Bd.   60. 


SEROUS  INDUCED  LABYRIXTHITIS  89 

The  fourth  group  is  the  most  important,  not  only  because 
it  occurs  most  frequently,  but  also  because  of  its  post- 
operative character,  which  fact  imposes  upon  us  special 
care  in  judging  this  clinical  manifestation. 

In  general,  the  induced  serous  labyrinthitis  appears  in 
from  one  to  three  days  after  the  radical  operation.  Most 
frequently  the  symptoms  appear  suddenly,  when  the  patient 
is  feeling  unusually  well,  having  recovered  from  the  un- 
i:>leasant  effects  of  the  anesthetic  and  the  operative  shock. 
These  symptoms  are  nystagmus  to  the  healthy  side,  vertigo, 
emesis,  disturbances  of  equilibrium  (lying  upon  the  well 
side).  The  functional  test  shows  a  marked  diminution  of 
hearing  or  total  deafness  on  the  diseased  side,  with  retained 
caloric  reaction. 

In  our  cases  the  hearing  was  diminished  while  the  ca- 
loric reaction  was  retained  nine  times ;  the  hearing  was  en- 
tirely absent  while  the  caloric  reaction  was  retained  three 
times. 

Naturally,  from  the  analogj'^  with  the  diffuse  serous  sec- 
ondary labyrinthitis,  and  in  consideration  of  the  cases  of 
Voss,  we  must  assume  that  there  are  cases  of  serous  laby- 
rinthitis with  obliterated  hearing  and  obliterated  caloric 
reaction.  But  such  cases  we  have  been  obliged  to  class  with 
the  diffuse  purulent  form,  inasmuch  as  we  are  usually  un- 
able to  differentiate  them  clinically. 

In  the  serous  labyrinthitis  sometimes,  but  really  very 
seldom,  do  we  see  nystagmus  to  the  diseased  side.  Accord- 
ing to  Alexander,  this  would  represent  a  stage  of  irrita- 
tion; but  we  are  more  inclined  to  believe  that  in  these  eases 
it  is  a  matter  of  an  undeveloped  serous  labyrinthitis,  or  it 
is  the  production  of  attacks  of  nystagmus  by  head 
movements. 

We  must  come  to  this  conclusion  after  the  observation 
of  labyrinth  fistulae.  In  these,  since  the  circumscribed 
focus  is  already  within  the  labyrinth,  the  serous  labyrinthi- 
tis appears  very  rapidly  after  the  operation,  and  we  are  in 
a  position  to  observe  even  the  very  beginning  of  the  proc- 


90  DISEASES  OF  THE  LABYBINTH 

ess,  for  our  attention  is  already  directed  to  the  labyrinth. 
In  these  cases  we  were  almost  always  able  to  notice  that 
the  nystag-nius  at  its  onset  is  regularly  directed  toward  the 
healthy  side.  We  can  imagine  that  the  induced  serous  laby- 
rinthitis is  sometimes  preceded  by  a  sort  of  circumscribed 
inflammation,  especially  when  it  is  a  case  of  migratory  laby- 
rinth disease. 

The  induced  serous  labyrinthitis  may  develop  into  a  dif- 
fuse purulent  labyrinthitis.  This  we  are  forced  to  conclude 
when  the  labyrinth  function  is  completely  lost  (Cases  101, 
70,  68,  63).  In  such  a  case  the  indication  for  a  labyrinth 
operation  is  clear. 

It  remains  to  be  mentioned  that  simultaneously  with  the 
milder  affections  with  complete  loss  of  function,  and  also 
in  both  the  induced  and  in  the  secondary  diffuse  serous 
labyrinthitis,  a  facial  paresis  may  appear.  This  we  must 
assume  to  be  caused  by  the  same  inflammatory  exudative 
process  in  the  facial  canal.  Compare  the  cases  of  Bondy* 
and  of  Ernst  Urhantschitsch.j- 

The  duration  of  the  severe  symptoms  is  generally  three 
to  eight  days,  when  a  continuous  diminution  is  the  rule. 

♦  Austrian  Otol.  Soc,  Oct.,  1908,  M.  f.  O.  XLIII,  Heft  3. 
tAustrian  Otol.  Soc.,  Oct.,  1909,  M.  f.  O.  XLIII,  Heft  11. 


CHAPTER  V 
LABYRINTHITIS  AND  BRAIN  ABSCESS 

AVe  find  eight  of  our  cases  combined  with  brain  abscess. 
There  occur  in  the  literature  a  large  number  of  such  cases. 
Of  our  cases,  four  were  temporal  lobe  abscesses  and  four 
were  cerebellar  abscesses.  In  addition,  there  are  two  cases 
of  cured  cerebellar  abscess  proceeding  from  labyrinth  sup- 
puration, which  are  reported  separately.  So  we  have  six 
cases  of  cerebellar  abscess  in  connection  with  labyrinth 
suppuration ;  that  is,  we  must  assume  this  with  the  observa- 
tion that,  although  it  is  not  entirely  impossible,  one  or 
more  cases  are  less  likely  to  have  proceeded  from  the  laby- 
rinth suppuration  as  such  {i.e.  through  the  internal  audi- 
tory meatus)  than  from  the  destruction  of  bone  about  the 
labyrinth.  Wagener  has  beautifully  shown  how  difficult  it 
is  to  differentiate  between  such  cases.  In  a  cerebellar 
abscess  not  of  labyrinthine  origin  the  course  of  the  infec- 
tion is  not  always  as  clear  as  in  a  case  which  I  reported.* 
Often  there  may  be  extensive  destruction  of  the  paralaby- 
rinthine  bone,  but  the  labyrinth  itself  may  be  quite  intact. 

On  the  other  hand,  the  four  cases  of  temporal  lobe 
abscess,  as  shown  by  the  postmortem,  were  certainly  not  de- 
pendent upon  labyrinth  suppuration,  but  were  caused  by 
destruction  of  the  tegmen  antri  or  tympani  and  the  con- 
secutive pachymeningitis  externa  and  interna. 

Of  the  six  cases,  four  occurred  in  connection  with  puru- 
lent and  two  in  connection  with  serous  labyrinthitis. 

The  combination  of  a  labyrinthitis  and  a  cerebellar 
abscess  is  not  a  rare  one,  but  one  in  which  the  diagnosis 
and  treatment  are  especially  difficult.  The  symptoms  in 
both  may  be  entirely  similar  and  the  differential  diagnosis 
may  be  quite  impossible.     But  many  cases  do  permit  of 

*M.  f.  O.  Nr,  4,  43rd  year, 

91. 


92  DISEASES  OF  THE  LABYRINTH 

a  fairly  certain  differential  cliaguosis,  that  is,  those  eases 
in  which  the  symptom  given  by  Neumann  and  Bdrduy,  i.e. 
nystagmus  to  the  diseased  side,  is  present  when  the  laby- 
rinth is  wholly  destroyed.  We  are  able  to  diagnose  with 
certainty  a  brain  abscess  by  the  nystagmus  to  the  diseased 
side  when  there  is  positively  a  labyrinth  suppuration  (com- 
plete deafness  with  loss  of  reaction  of  the  labyrinth  for  all 
tests:  caloric,  turning  and  fistula  tests),  provided  that  the 
other  labyrinth  is  not  affected.  We  know  that  in  complete 
destruction  of  the  labyrinth  there  is  either  nystagmus  to 
the  healthy  side  (that  is,  for  a  short  time  after  the  destruc- 
tion), or  there  is  no  nystagmus  (that  is,  some  little  time 
after  the  destruction  has  taken  place).  Nystagums  to  the 
diseased  side  in  such  a  case  can  only  result  from  retrolaby- 
rinthine  causes ;  namely,  from  a  meningitis  in  the  posterior 
cranial  fossa,  or  from  a  cerebellar  abscess.  In  purulent 
meningitis  the  nystagmus  will  increase,  as  shown  by  'Neu- 
mann; but  in  serous  meningitis,  as  I  have  pointed  out,  it 
will  decrease.  With  cerebellar  abscess  the  nystagmus  will 
either  remain  constant  (more  often,  though,  it  varies  sud- 
denly and  it  is  quite  characteristic  for  us  to  see  in  the 
course  of  a  day  periods  in  which  the  patient  is  entirely  free 
from  nystagmus,  these  periods  alternating  with  severe  nys- 
tagmus to  the  diseased  side),  or  the  nystagmus  changes  its 
direction;  that  is,  if  we  examine-  the  patient,  for  instance, 
in  the  forenoon,  we  may  find  nystagmus  to  the  diseased 
side ;  in  the  afternoon,  the  nystagmus  is  to  the  healthy  side. 

Naturally,  other  symptoms  may  appear  besides.  Ver- 
tigo, emesis,  equilibrium  disturbances  are  then  only  of  sig- 
nificance in  diagnosing  a  cerebellar  abscess,  if  we  know 
positively  that  the  labyrinth  is  completely  without  function.. 
As  long  as  this  is  not  the  case,  it  is  doubtful  whether  this 
symptom  is  produced  by  the  labyrinth  or  has  its  origin 
within  the  cranium. 

On  the  other  hand,  slowing  of  the  pulse  is  not  naturally 
occasioned  by  the  labyrinth,  and,  besides,  the  nystagmus 
points  most  surely  to  an  abscess.    Likewise,  fever  is  never 


LABYEIMHITIS  AXD  BEAIN  ABSCESS  93 

to  be  ascribed  to  a  simple  labyrinth  disease,  but  suggests 
a  complication..  Should  the  cerebellar  abscess  be  combined 
with  a  circumscribed  or  a  serous  labyrinthitis,  the  diagno- 
sis becomes  even  more  difficult.  In  circumscribed  laby- 
rinthitis the  nystagmus  is  quite  as  likely  to  be  directed  to- 
ward the  healthy  side  as  toward  the  diseased  side,  and  thus 
it  is  not  to  be  distinguished  from  a  cerebellar  nystagmus. 
And  in  the  serous  labyrinthitis,  as  long  as  the  labyrinth 
still  performs  any  of  its  functions,  we  are  not  at  all  sure 
of  the  matter.  If  a  serous  labyrinthitis  has  run  its  course 
and  the  labyrinth  retains  its  functions,  then  attacks  of  nys- 
tagmus to  the  diseased  side  would  still  be  possible.  In  such 
cases,  therefore,  as  I  have  already  proposed,  we  must  first 
exclude  the  labyrinth  by  the  labyrinth  operation.  Then 
we  may  utilize  for  the  diagnosis  of  a  cerebellar  abscess  a 
spontaneous  nystagmus  still  persisting  after  the  labyrinth 
operation,  if  it  is  toward  the  diseased  side,  or  is  alternately 
directed  to  the  healthy  and  to  the  diseased  side.  Naturally, 
the  operation  must  completely  destroy  the  labyrinth,  for 
which  reason  nothing  short  of  the  opening  anteriorly  and 
posteriorly,  that  is,  Neumann's  method,  is  to  be  recom- 
mended. Opening  the  labyrinth  simply  from  in  front  is  not 
sufficient,  for  nerve  elements  might  be  left,  which,  after 
the  labyrinth  operation,  could  produce  nystagmus  to  the 
operated  side,  as  in  Case  4. 

In  a  case  of  suspected  cerebellar  abscess  or  of  meningitis, 
our  procedure  accordingly  is  as  follows:  In  a  case  with 
spontaneous  nystagmus  to  the  diseased  side,  when  the  laby- 
rinth is  entirely  excluded,  we  perform  the  labyrinth  opera- 
tion with  exposure  of  the  dura  of  the  posterior  fossa  ac- 
cording to  rule. 

If  we  find  the  dura  pathologically  altered,  we  incise  it 
and  look  for  the  abscess.  If  the  dura  is  normal,  we  wait 
a  while,  in  order  that  we  may  positively  exclude  any  other 
disease  (tuberculosis,  tumor,  etc.),  and  make  the  incision 
only  after  no  other  possibility  remains,  except  an  otogenous 
abscess  or  meningitis. 


94  DISEASES  OF  THE  LABYRIXTH 

If  there  is  spontaueoiis  nystagmus  to  the  affected  side 
ill  a  case  in  which  the  hibyriuth  has  not  been  entirely  ex- 
cluded, then  we  first  perform  the  labyrinth  operation  with 
exposure  of  the  dura  of  the  posterior  fossa,  and,  at  all  events, 
wait  to  see  if  the  nystagmus,  after  having  thus  excluded 
the  labyrinth,  still  remains  of  the  same  degree  or  is  of 
changing  intensity.  If  this  is  the  case,  we  make  the  in- 
cision and  look  for  the  abscess.  In  these  cases,  a  nystag- 
mus directed  to  the  diseased  side  is  more  significant,  for, 
by  the  very  opening  of  a  labyrinth  which  is  not  completely 
destroyed,  a  nystagmus  toward  the  healthy  side  is  called 
forth. 

We  will  now  examine  our  cases  more  closely.  In  Case  11 
there  was  a  circumscribed  labyrinthitis,  which,  after  the 
operation,  was  transformed  into  a  diffuse  secondary  or  a 
purulent  manifest  labyrinthitis.  Unfortunately  the  fistula 
test  was  not  made  after  the  operation,  which  would  have 
differentiated  between  these  two  forms.  This,  however, 
would  have  been  only  of  theoretical  interest,  for,  practi- 
cally, we  were  obliged  to  open  the  labyrinth,  for  fever,  head- 
ache, slight  rigidity  of  the  neck,  namely,  the  sjTuptoms  of 
an  intracranial  complication,  were  present,  besides  the  dif- 
fuse labyrinthitis.  After  the  operation  there  appeared  the 
typical  nystagmus  to  the  well  side,  and  for  six  days  every- 
thing seemed  to  go  well,  with  diminution  of  the  fever.  It 
is  all  the  more  noteworthy  that  on  the  seventh  day,  as  the 
first  symptom  of  a  cerebellar  abscess,  there  appeared  nys- 
tagmus to  the  diseased  side,  emesis  and  headache,  though 
the  temperature  remained  normal.  During  the  following 
days  the  nystagmus  changed,  alternating  from  the  diseased 
to  the  well  side,  varying  also  in  intensity.  Both  of  these 
symptoms  must  cause  us  to  think  of  cerebellar  abscess,  had 
the  other  symptoms  (apathy,  occipital  headache,  stiffness 
of  the  neck)  not  been  present. 

In  Case  12  there  was  a  circumscribed  labyrinthitis. 
After  the  radical  operation  there  came  on  a  typical  diffuse 
serous  secondary  labyrinthitis,  with  marked  spontaneous 


LABYRIXTHITIS  AXD  BKAIX  ABSCESS  95 

nystagmus  to  the  healthy  side,  which  destroyed  the  hear- 
ing but  left  the  caloric  reaction.  Within  three  days  this 
nystagmus  subsided  in  the  typical  manner;  on  the  third 
day  there  was  left  only  nystagmus  of  the  first  degree  to 
the  healthy  side.  All  the  more  suspicious  was  the  appear- 
ance on  the  fourth  day  of  a  nystagmus  to  the  diseased  side; 
since  there  was  present  not  another  symptom  of  cerebellar 
abscess,  and  the  neurological  and  ophthalmological  exami- 
nations were  entirely  negative,  we  made  the  mistake  of 
waiting.  The  patient  surprised  us  the  next  day  by  loss 
of  consciousness  and  contractions  on  the  opposite  side*  of 
his  body.  Immediately  the  labyrinth  operation  was  per- 
formed with  opening  of  the  cerebellar  abscess,  but  the  pa- 
tient died  three  days  later  of  meningitis. 

It  is  interesting  that  in  Case  11  there  was  fever,  but  Case 
12  was  continuously  free  from  fever  until  one  day  before 
death.  Likewise,  in  both  cases  there  was  no  slowing  of  the 
pulse. 

In  Case  70  there  also  occurred  at  first  a  serous  labyrinthi- 
tis following  the  radical  operation,  which,  not  until  four- 
teen days  later  (the  exact  time  of  its  appearance  could  not 
be  established),  became  purulent.  The  nystagmus  during 
the  entire  time  was  directed  to  the  healthy  side.  Even  one 
day  after  the  labyrinth  operation  the  nystagmus  still  con- 
tinued unchanged.  But  on  the  second  day,  in  addition  to 
the  nystagmus  to  the  healthy  side,  which  now  changed  its 
character  and  became  decidedly  horizontal,  there  appeared 
a  distinctly  rotatory  nystagmus  to  the  diseased  side,  and 
also  a  vertical  nystagmus.  Even  before  the  labyrinth 
operation,  because  of  the  temperature  and  the  headache, 
there  was  reason  to  suspect  an  intracranial  complication. 
Inasmuch  as  upon  operating,  the  dura  behind  the  opened 
vestibule  was  found  to  be  greatly  changed,  the  suspicion 
of  cerebellar  abscess  was  so  strong  that  search  was  made 
for  it.  But  the  incision  was  in  vain.  Because,  two  days 
later,  the  above-mentioned,  I  may  say,  exaggerated  or  ''ex- 
traordinary" nystagmus  appeared,  our  earlier  diagnosis. 


96  DISEASES  OF  THE  LABYEINIH 

in  spite  of  the  negative  result  of  our  incision,  ^as  con- 
firmed, and  we  explored  once  more  and  found  the  abscess. 
And  here  again  the  nystagmus  was  a  very  important  symp- 
tom. I  wish  to  again  call  attention  to  the  fact  that  every 
** extraordinary"  nystagmus  points  to  an  intracranial  com- 
plication. I  should  designate  as  *' extraordinary"  every 
nystagmus  which  does  not  fall  within  the  type  character- 
istic of  a  circumscribed  or  diffuse  labyrinthitis.  The  type 
for  the  circumscribed  labyrinthitis,  as  we  have  already  seen, 
is  a  rotatory  or  a  horizontal  nystagmus  to  the  healthy  or 
to  the  diseased  side,  or  to  both  sides.  The  type  for  the 
diffuse  labyrinthitis  (that  is,  for  a  diffuse  serous  or  a  dif- 
fuse purulent  manifest  labyrinthitis,  or  for  any  sudden 
labyrinth  exclusion  or  destruction)  is  severe  rotatory  nys- 
tagmus to  the  healthy  side.  Any  other  nystagmus,  as,  for 
instance,  a  vertical  or  diagonal  nystagmus,  points  to  an  in- 
tracranial origin,  which  we.  are  not  only  able  to  conclude 
from  the  observed  abscesses,  but  also  from  a  large  num- 
ber of  cerebellar  tumors,  cerebellar  tubercles,  tumors  of 
the  pons  and  acusticus  tumors. 

Case  68  on  the  third  day  (characteristic)  after  the  radi- 
cal operation  complained  of  vertigo.  On  this  day  the  laby- 
rinth, ^vhich  even  before  the  operation  appeared  not  to  be 
intact,  yet  showed  no  definite  lesion  (hearing  present  only 
for  loud  voice  at  the  external  ear,  caloric  reaction  plain,  but 
weak,  and  not  associated  with  vertigo,  some  spontaneous 
nystagmus  to  the  healthy  side,  as  the  functional  test 
showed),  was  in  the  same  state  as  before  the  operation. 
Since  the  hearing  remained  the  same  and  no  other  symp- 
toms appeared,  there  was  no  occasion  for  any  further 
operative  procedure.  Not  until  after  eight  days  did  there 
appear  headache,  nausea  and  elevation  of  temperature  and 
an  extraordinary  nystagmus  (horizontal  on  looking  to  the 
left,  rotatory  on  looking  to  the  right),  which  was  also  in 
part  directed  to  the  diseased  side.  The  functional  test  now 
showed  total  failure  of  labyrinthine  function  (deafness,  no 
caloric  reaction,  no  turning  reaction,  no  fistula  symptom). 


LABYRINTHITIS  AND  BRAIN  ABSCESS  97 

At  once  we  made  the  positive  diagnosis  of  labyrinth  sup- 
puration Avith  probable  diagnosis  of  cerebellar  abscess. 

The  patient,  however,  refused  any  further  operation, 
until  four  days  later  he  had  a  chill.  We  then  performed 
the  labyrinth  operation  with  exposure  of  the  dura  of  the 
posterior  fossa.  As  the  dura  appeared  normal,  we  waited. 
Another  internal  and  neurological  examination  proving 
negative,  and  the  fever  in  the  meantime  having  become 
pyaemic  in  character,  I  swerved  from  my  diagnosis  and 
only  tied  off  the  jugular  vein  and  cleaned  out  the  sinus, 
which  was,  in  fact,  thrombosed.  This  course  seemed  the 
more  justifiable,  for  any  special  headache  and  slowing  of 
the  pulse  were  entirely  absent  and  the  patient  insisted  that 
he  was  doing  w^ell.  But  the  signs  of  a  thrombosis  of  the 
cavernous  sinus  increased  more  and  more,  and  finally  the 
patient  died.  The  postmortem  showed,  besides  a  cavernous 
sinus  thrombosis  extending'  from  the  petrosal  sinus  and  a 
basal  meningitis,  also  a  cerebellar  abscess. 


CASE  HISTORIES 

Abbreviations 


R.e.  =  Right  ear. 

L.e.  =  Left  ear. 

Con.v.      =  Conversational  voice. 

Whisp.v.  =  Whispered  voice. 


w. 

=  Weber. 

R. 

=  Rinne. 

Sch. 

=  Schwabach. 

F.t. 

=  Fistula  test. 

C.r.,  or 

eal.  react 

.=:  Caloric  reaction. 

a.c. 

=  Ad  concham. 

Ny. 

=  Nystagmus. 

Ny.  r. 

=  Nystagmus  to  the  right. 

Ny.l. 

=  Nystagmus  to  the  left. 

Short. 

=  Shortened. 

Rotat. 

=  Rotatory. 

Leng. 

=  Lengthened. 

R.tr. 

=  Turning  to  the  right  and 

L.tr. 

=  Turning  (rotation)  to  tl 

motion. 
B.s.  syr.  al.  =  Both  sides  syringed  alike. 
"  =  Mark  for  seconds. 

'  =  Sign  for  minutes. 

O.P.  Dept.  =  Out  Patient  Department. 
Temp.  =  Temperature. 

1-  L.  H.  Thirty-three  years  old.  Bronzeworker.  Ad- 
mitted July  10,  1907. 

Anamnesis:  Patient  visited  the  clinic  one  year  ago  on 
account  of  pain  in  r.  ear.  Polyps  were  removed,  after  which 
there  followed  a  discharge,  which  ceased  after  five  weeks  of 
treatment.    During  the  past  four  weeks  the  discharge  has 

98 


CASE  HISTORIES  99 

returned,  with  pain.  Sensitive  to  pressure  over  tragus  and 
mastoid.  Since  removal  of  polyps,  hearing  is  less  acute. 
Occasional  severe  vertigo. 

Status  praesens:  E.e. :  Thick,  non-smelling  secretion, 
with  many  scales  of  epidermis  (no  cholesterin).  Upper 
posterior  meatal  wall  bulging.  Large  polyp  from  above, 
filling  entire  meatus.  Mastoid  not  sensitive  to  pressure. 
L.e. :  Membrane  retracted,  cloudy  and  atrophic. 

Functional  test:  Con. v.,  1.  8  m.,  r.  i/o  m.;  Whisp.v.,  1.  3  m., 
r.  i/o  m.  W.  1. ;-  R.  —  b.s.  Bone  conduction,  r.  shortened, 
1.  lengthened.  Ci  b.s.  shortened,  C^  r.  shortened;  1.  normal. 
Caloric  ny.  to  r.  normal. 

Pressure  in  the  external  auditory  meatus  produces  ver- 
tigo and  rotatory  ny.  to  r. 

R.tr.  =  Xy.  l.*20'''.    L.tr.  =  Ny.  r.  20".      * 

Temperature:  Before  operation,  normal.  After  opera- 
tion—July 28  (second  day),  37.5;  July  29,  37.7;  July  30, 
36.7 ;  July  31,  37.8 ;  Aug.  1,  37.5.    Thereafter,  below  36.0. 

Operation:  Typical  radical  operation.  Cholesteatoma 
fills  antrum  and  tympanum ;  oval  fistula  in  horizontal  semi- 
circular canal.  Dura  of  middle  fossa  exposed  over  an  area 
the  size  of  a  bean. 

July  26 :  Two  hours  after  the  operation  patient  had  ny. 
to  both  sides.  Severe  rotatory  ny.  to  1.,  even  on  looking 
straight  forward. 

July  27 :  Since  the  operation  yesterday,  patient  has  vom- 
ited every  ten  minutes.  Has  not  slept.  Vertigo  only  upon 
raising  his  head.  Slight  rotatory  ny.  to  1.  on  looking  for- 
ward, more  pronounced  on  looking  to  1.  On  looking  to  r., 
only  a  slow,  large  horizontal  ny.  to  r. 

July  28:  No  emesis  since  yesterday.  Rotat.  ny.  to  1., 
slight  horizontal  ny.  to  r.    Temp.  37.5. 

July  29 :  Vertigo  only  on  standing.  Rotat.  ny.  to  1.,  slight 
or  no  ny.  to  r.    Temp.  37.7. 

July  30 :  Patient  feels  decidedly  better.  Vertigo  only  on 
standing.  Xy.  diminished.  Rotat.  ny.  to  1.,  no  ny.  to  r. 
Temp.  36.7—37.4. 


100  DISEASES  OF  THE  LABYRINTH 

July  31 :  No  vertigo.    Eotat.  ny.  to  1.  37.8. 

Aug.  1 :  No  vertigo.    No  ny.  37.5. 

Aug.  3 :  First  dressing.  Wound  shows  no  reaction.  No 
vertigo,  no  ny.    Temp,  normal. 

Aug.  5 :  Second  dressing.  Wound  shows  no  reaction.  No 
vertigo,  no  ny. 

Aoig.  7:  Patient  feels  well.  Transferred  to  out-patient 
department. 

Aug.  11:  Dressed.  Few  granulations.  Whisp.v.  well 
heard  with  conversation  tube.  No  vertigo,  ny.  with  large 
movement  of  eyes  to  both  sides,  stronger  to  the  1.  than  to 
the  r. 

Aug.  13:  Dressed.  No  vertigo.  Slight  rotat.  ny.  to  r. 
Wound  without  reaction. 

Aug.  30 :  With  conversation  tube  hears  Whisp.v.  without 
error.    No  vertigo  or  ny. 

Sept.  1 :  No  vertigo,  no  spontaneous  ny.  With  conversa- 
tion tube  hears  Whisp.v.  repeated  without  mistakes.  With 
cold  water,  slight  if  any  reaction.  Turning  to  r.  =  rotat. 
after-ny.  to  1.    Duration,  looking  forward  =  15''. 

Sept.  14:  No  vertigo,  no  spontaneous  ny.  With  conver- 
sation tube  Whisp.v.  repeated  with  few  mistakes.  Turning 
to  1.  =  horizontal  after-ny.  to  r.  12".  Turning  to  r.  =  hori- 
zontal after-ny.  to  1.  12''. 

10  revolutions  to  1.,  head  forward,  =  rotat.  after-ny.  to 
r.,  13". 

10  revolutions  to  r,,  head  forward,  =  rotat.  after-ny.  to 
1.,  13". 

The  horizontal  ny.  after  rotation  is  alike  on  both  sides 
and  consists  of  small  movements.  The  rotat.  ny.  after  turn- 
ing is  likewise  equal,  but  of  coarser  movements  of  the  eyes. 

Both  sides  react  alike  after  cold  water  irrigation. 

Sept.  20:  Hears  less  than  before.  With  conversation 
tube,  con.v.  heard  with  mistakes ;  small  spontaneous  rotat. 
ny.  to  both  sides.  Turning  to  1. :  Horizontal  after-ny.  to  r., 
11".    Turning  to  r. :  Horizontal  after-ny.  to  1.,  19". 

Head  inclined  forward,  after  10  revolutions  to  1.,  rotat. 
ny.  to  r.,  13". 


CASE  HISTORIES  101 

Head  inclined  forward,  after  10  revolutions  to  r.,  rotat. 
ny.  to  1.,  18^'. 

Second  admission  to  hospital  Mch.  8,  1909. 

Anamnesis :  Nine  months  after  the  operation,  discharge 
from  ear  returned.  Local  treatment  caused  cessation  for 
a  while,  but  discharge  soon  began  again.  Patient  states 
that  he  had  vertigo  only  four  weeks  after  first  operation; 
none  since.  No  emesis,  and  headache  only  when  the  dis- 
charge ceases.    Never  has  fever. 

Status  praesens:  L.  ear:  membrane  normal.  R.  ear: 
Eetro-auricular  scar.  Granulations  fill  antrum  and  tym- 
l^anic  cavity.  No  fever.  L.  ear  normal;  r.  ear  deaf  for 
speech  and  tuning  forks.  W.  in  the  head.  R.  bone  conduc- 
tion shortened.  Ci  =  0.  C^  =  0.  F.t.  negative.  C.r. 
prompt,  with  vertigo. 

Operation,  Mch.  13  (Ruttin) :  Skin  incision  through  the 
old  scar.  Periosteum,  altered  by  scar,  pushed  aside.  Sinus 
and  dura  of  posterior  cerebral  fossa  at  the  level  of  the 
upper  bend  of  the  sinus  as  large  as  a  heller  piece  lies  ex- 
posed, and  this  area  is  drawn  by  scar  tissue  into  the  cavity. 
In  the  opened  antrum  and  tympanic  cavity,  abundant 
cholesteatomatous  masses.  After  curetting  these  away, 
there  is  visible,  on  the  horizontal  semicircular  canal,  a  cap- 
like, yellow,  sharply  defined  exostosis,  which  plainly  closed 
the  former  fistula.  Facial  prominence  smoothed.  Eusta- 
chian tube  curetted.  A  typical  plastic  retro-auricular 
closure  of  the  wound.  Dressing.  After  the  operation  no 
ny.  except  the  narcosis  ny.  Very  carefully  watched  for  sev- 
eral days.    No  vertigo. 

Mch.*14,  37.6;  Mch.  15,  36.7;  Mch.  16,  36.0;  Mch.  17,  37.5. 
First  change  of  dressing.  Cavity  shows  granulations,  some 
discharge.    C.r.  typical.    Total  deafness.    Temp,  is  normal. 

2,  K.  V.  Age  29.    Admitted  Dec.  5, 1907.' 

Anamnesis :  Occasional  discharge  for  fifteen  years.  Suf- 
fers often  from  vertigo. 

Status  praesens:  L.e. :  A  large  polyp  fills  the  lower  part 
of  the  external  meatus.    Abundant  discharge.    At  present 


102  DISEASES  OF  THE  LABYEIMII 

the  patient  suffers  little  pain,  though  previously  she  liad 
severe  headache,  particularly  over  the  I.e.  R.e.  is  normal. 
Functional  test:  R.e.  normal.  L.e.  deaf  for  speech  and 
tuning  forks.  W.  lateralized  to  1.  R.  — .  Sch.  shortened. 
Ci  0,  C^  0,  spont.  ny.  rotatory  to  1.  C.r.,  after  prolonged 
syringing,  0.  After  tr.  r.,  ny.  1.  =  12",  after  tr.  1.,  ny.  r. 
=  12".  The  fistula  sjinptora  was  easily  demonstrated  yes- 
terday. Xy.  rotat.  1.  Now  no  vertigo,  according  to  pa- 
tient's statement.  But  only  two  days  ago,  when  she  was 
urged  to  enter  the  hospital,  which  she  tried  to  avoid,  she 
stated  that  she  frequently  had  severe  vertigo.  She  has  also 
lately  been  forgetful. 

Neurological  findings:  Patellar  reflex  absent.  Sugges- 
tion of  ataxia  in  r.  arm.    Fundus  normal. 

Operation,  Dec.  6  (Prof.  Urbantschitsch) :  Typical  radi- 
cal operation.  Sinus  lies  far  forward.  It  is  exposed  about 
2  cm.,  showing  its  wall  to  be  normal.  Exposure  of  the  dura 
of  the  posterior  fossa  in  front  of  the  sinus,  and  of  the  mid- 
dle fossa  the  size  of  a  heller.  The  dura  of  the  middle  fossa 
covered  with  slight  exudate.  The  dura  of  the  posterior 
fossa  normal.  Typical  labyrinth  operation.*  Abundant 
discharge  of  fluid  from  the  labyrinth.  In  the  horizontal 
semicircular  canal  at  the  juncture  of  the  lateral  and  median 
portions  there  is  a  fistula,  discolored  brownish  black,  about 
1  mm.  long,  whose  patency  is  demonstrated  with  a  probe. 
Plastic;  dressing.  After  the  operation,  ny.  rotatory  r., 
large  and  rolling;  vertigo,  emesis,  patient  lies  on  her  right 
side. 

Dec.  7:  Temp.  37.7. 

Dec.  8 :  Ny.  not  so  marked.    Temp,  normal  until  Dec.  12. 

Dec.  12:  Temp,  rises  to  38.0. 

Dec.  13:  First  dressing.  Ny.  diminished,  but  quite 
marked  on  looking  toward  the  healthy  side.  Dressing  some- 
what permeated  by  the  liquid.  No  secretion.  Beginfling 
discharge.    Temp.  38°. 

*Here,  as  in  all  the  following  case  histories,  we  understand  by  "typical  laby- 
rinth operation"  the  method  of  Neumann,  but,  upon  principle,  not  extending 
to  the  internal  auditory  meatus. 


CASE  HISTORIES  103 

Dec.  15:  Second  dressing.  Slight  discharge.  Tempera- 
ture normal. 

Dec.  17:  Dressed.  Transferred  to  out-patient  depart- 
ment. 

3.  M.  U.  Age  58.    Admitted  Jan.  3, 1908. 
Anamnesis:    R.e.  diseased  for  two  years.     For  a  time, 

discharge.  Two  months  ago  severe  discharge  again  came 
on,  together  with  vomiting  and  severe  vertigo,  and  very 
severe  pains  in  the  head  on  the  right  side. 

Status  praesens:  R.e.,  large  perforation  in  posterior 
quadrant  into  the  antrum  and  attic.  Mucus  membrane 
granulating.  Lower  jDortions  preserved;  short  process  of 
hammer  visible.    L.e.  normal. 

Temperature:  37.2. 

Functional  test:  L.  normal.  R.  Con.v.  ad  concham.  W. 
rt.,  R.  -f .  Ci  -f-,  C"*  + ;  spontaneous  ny.  horizontal  to  both 
sides,  with  rotatory  component  on  looking  to  1.  Fistula 
test  H",  with  vertigo  and  nausea.    Caloric  reaction  -f-. 

Operation,  Jan.  4,  1908  (Prof.  Urbantschitsch) :  Typical 
radical  operation.  Cholesteatoma  in  the  widened  antrum. 
In  the  horizontal  semicircular  canal  at  an  angle  of  45°  with 
its  axis  a  fistula  about  4  mm.  by  1  mm.  The  dura  of  the 
middle  fossa  lies  low.  It  was  exposed  for  an  area  the  size 
of  a  heller,  and  is  normal.    Sinus  not  exposed;  no  ossicles. 

Temperature:  Jan.  4,  38;  Jan.  5,  37.6  and  36.4. 

Jan.  6 :  Ny.  toward  healthy  side.    Temp.  37.1. 

Jan.  7 :  Temp.  37.3 ;  Jan.  8,  36.4,  37.4. 

Jan.  9 :  Dressing  changed  because  of  temp,  of  38.2.  Deaf 
when  tested  with  exclusion  apparatus.  Labyrinth  does  not 
respond  (syringed  at  24°).  Ny.  to  healthy  side  unchanged. 
Fistula  still  demonstrable. 

Jan.  10 :  Temp.  36.8,  38.0.  Jan.  11,  37.5,  from  which  date 
it  is  practically  normal. 

Feb.  2,  1908:  No.  n3\  Condition  good.  Transferred  to 
out-patient  department. 

4.  M.  H.  Age  30.  Cashier.  Admitted  Jan.  28,  1909. 


104  DISEASES  OF  THE  LABYRINTH 

Anamnesis :  Discharging  ear  one  year  ago,  with  pains 
on  both  sides,  improved  under  treatment.  A  few  days  ago, 
following  a  coryza,  severe  pain  behind  left  ear.  More  re- 
cently also  continuous  tinnitus,  vertigo  and  attacks  of  faint- 
ing. Previously  she  had  from  time  to  time  vertigo  with 
apparent  movement  of  objects,  nausea,  anorexia. 

Status  praesens:  L. :  Griesinger's  symptom.  Jugular  re- 
gion sensitive  to  pressure.  Internal  and  neurological  con- 
dition normal.    E.e.  normal.    L.e.  chronic  suppuration. 

Functional  test:  Con.v.  2  m.  Whisp.v.  ad  concham; 
buzzing  noise  in  jugular  audible.  W.  1.,  E.  — .  Bone  con- 
duction scarcely  lengthened.  Ci  0,  C^,  when  struck  hard. 
Vertigo.  No  spont.  ny.,  no  fistula  symptom.  Caloric  ny. 
prompt. 

Operation,  Feb.  1  (Prof.  V  rh  ants  chits  cli) :  Pneumatic 
mastoid.  Exposed  sinus  normal,  only  at  one  small  point 
adherent  to  the  bonej  attempt  at  removing  this  caused 
bleeding. 

Feb.  2 :  Pain  in  1.  arm.  Rotatory  ny.  to  r.  and  1.  about 
equal. 

Feb.  3:  Pain  in  1.  shoulder.  Better  in  the  arm.  Ny. 
equal.    37.0,39.1. 

Feb.  4:  Headache,  ny.  equal;  38.8.  Emesis.  Dressing 
changed.  The  sinus,  where  exposed,  yellow.  Diagnostic 
puncture  of  sinus.  Circulation  in  sinus  diminished.  Liga- 
tion of  jugular  vein.  Thrombus  cleared  out.  Excision  of 
outer  wall  of  sinus  after  packing.  (During  anaesthesia,  the 
caloric  test  was  made.    Typical  result.) 

Feb.  5:  Headache  less.  Ny.  as  before.  Emesis  slight. 
36.5°,  37.7°.  From  now  on  temp,  normal,  except  for  occa- 
sional elevations  to  37.4. 

Feb.  6:  Headache.  Neck  sensitive.  Dressing  changed. 
Packing  removed  from  sinus.  No  bleeding.  Cal.  react, 
typical.  Hears  con.v.  (with  exclusion  test  and  conversation 
tube)  perfectly.  W.  1.  Middle  fork  not  heard  near  ear. 
C,  0,  C^  0. 

Feb.  7 :  Feels  well,  slight  headache.    Feb.  8,  same. 

Feb.  9:  Evening,  headache.    Ice  cap.    Morphine. 


CASE  HISrOEIES  105 

Feb.  10:  Severe  headache  at  vertex  and  occiput.  Pulse 
64.  Pupils  small  and  react  poorly.  Suggestion  of  ataxia 
of  the  upper  and  lower  extremities.  Keflexes  exaggerated. 
Skin  somewhat  hyperesthetic.  'Spine  sensitive  to  pressure. 
Kernig  negative. 

Fel).  11  to  12 :  Alternating  periods  of  headache  and  free- 
dom from  headache.  Pains  are  controlled  by  morphine. 
Urine  negative.    Wassermann  negative.    Thrombus,  sterile. 

Feb.  13 :  Pulse  96.  Patient  lies  more  upon  right  side,  and 
says  she  has  headache  and  vertigo  on  standing  or  lying  on 
left  side.  Xy.  rotat.  r.  =  ny.  rotat.  1.  Neurological  exam. 
negative,  except  for  ataxia  of  upper  extremities.  Dressing 
changed.    Inner  wall  of  sinus  heavily  covered  with  exudate. 

Feb.  14  to  17:  Patient  feels  well.  Slight  vertigo,  still 
present  on  standing.  Dressing  changed.  Eminence  of 
lateral  canal  not  granulating.  Median  wall  of  sinus  in  re- 
gion of  the  resection  of  the  lateral  wall  stretched  and  dis- 
colored. 

Mch.  4 :  The  deposit  in  the  sinus  gradually  clears  and  the 
patient  feels  better  from  day  to  day.  Headache  gradually 
less. 

Mch.  11 :   Transferred  to  out-patient  department. 

June  24, 1909 :  Patient  again  admitted  because  of  vertigo 
coming  on,  often  so  severely  as  to  make  her  believe  she 
might  fall  upon  the  street.  The  vertigo  persists  in  the 
hospital,  appearing  especially  upon  suddenly  moving  the 
head;  occasional  headache.  Sensation  of  dullness  in  head. 
Marked  vertigo  on  changing  dressing.  Fistula  symptom 
present  with  typical  ny.  to  diseased  side  on  compression. 
C.r.  prompt.    Spontaneous  ny.  to  both  sides. 

Operation,  July  8,  1909  (Prof.  Urbantschitsch) :  Granu- 
lations over  lateral  semicircular  canal  and  in  the  tympanic 
cavity.  Fistula  plainly  visible  in  horizontal  canal.  Semi- 
circular canal  at  site  of  fistula  and  the  promontory  opened. 
As  the  latter  was  opened,  a  drop  of  pus  appeared  in  the 
labyrinth.  Immediately  .following  the  operation  there  is 
noticeable  rotat.  ny.  to  r.  side,  and  a  much  quicker,  smaller 
nv.  to  the  1. 


106  DISEASES  OF  THE  LABYEIMH 

July  8:  7  P.M.  Ny.  unchanged.  Vertigo  on  turning. 
Pulse  irregular,  82. 

July  9 :  Kotat.  ny.  r.  perhaps  more  marked  than  yester- 
day.   Pulse  strong,  regular,  •64. 

July  10:  Rotat.  ny.  r.  quite  marked.  Smaller  ny.  to  1. 
still  present. 

July  12:  ny.  r.  weaker;  1.  only  occasional. 

July  13 :  Condition  the  same.    Patient  gets  up. 

July  14 :  At  change  of  dressing,  very  minute  quantity  of 
pus  present.  Patient  has  severe  pain  on  touching  the  inner 
tympanic  cavity  ever  so  lightly.  After  dressing,  marked 
rotat.  ny.  to  diseased  side.    No  ny.  to  well  side. 

July  15:  Ny.  only  upon  looking  to  1.  and  down,  and  to 
r.  upward  of  about  equal  strength.  On  walking,  vertigo,  ap- 
parent rotation  of  objects  to  the  r.  and  downward.  Head- 
ache chiefly  in  the  1.  parietal  region. 

July  17:  Dressing  changed.  Wound  in  good  condition. 
After  dressing,  diecided  rotat.  ny.  1.,  slow  rotat.  ny.  r.  Feels 
relatively  well. 

July  21 :  Condition  the  same.     Headache. 

July  24 :  Ny.  to  diseased  side  very  marked  after  dressing. 

July  28 :  Dressed.  Patient  complains  of  pains  in  parie- 
tal region  and  occiput.    Small  rotat.  ny.  to  both  sides. 

July  30 :  Transferred  to  out-patient  department. 

Three  weeks  later  there  is  still  vertigo,  which  gradually 
diminishes.  Patient  able  to  walk  upon  street  with  greater 
confidence  than  before.  While  before  she  had  vertigo  even 
while  lying  down,  now^  this  is  felt  only  when  she  moves 
suddenly  and  objects  seem  to  turn  to  the  1.  Since  early  in 
August,  vertigo  appeared  quite  seldom,  and  since  early 
September,  even  after  rapid  movements,  she  is  free  from 
vertigo.    No  emesis  since  July  30. 

Now  there  is  only  headache,  irregular  in  its  appearance 
and  without  special  cause,  radiating  from  both  sides  into 
the  occipital  region.    Such  an  attack  lasts  one  to  two  hours. 

Oct.  27:  Entirely  free  from  vertigo,  even  on  sudden 
movement  of  head. 


CASE  HISTOFIES  107 

5.  Z.  Admitted  Nov.  26,  1907. 

Anamnesis:  Discharge  from  r.  ear  one  year  ago.  Then 
vertigo  for  two  weeks;  since  then  no  vertigo.  Occasional 
tinnitus.  For  past  three  months  no  tinnitus.  Severe 
phthisis. 

Status  praesens:  R.e.,  total  destruction,  foetid  suppura- 
tion, polyps.    L.e.  opaque  and  retracted. 

Functional  test:  L.  normal.  R.  deaf  for  speech  and  tun- 
ing forks.  W.  r.,  R.  — .  Rotat.  ny.  1.,  Sch.  20",  shortened; 
caloric  ny.  prompt  (little  vertigo) ;  fistula"  symptom  -\-,  and 
ny.  to  1.  on  compression. 

Feb.  16,  1908:  Same  findings,  except  reversed  fistula 
symptom.    Compression  ny.  to  r. 

6.  W.  J.  Age  40.  Mason's  helper.  Admitted  Aug.  24, 1908. 
Anamnesis :  Three  years  ago,  discharge  1.    R.e.  healthy. 

Vertigo,  particularly  on  bending  forward.  No  fever,  no 
other  symptoms. 

Status  praesens:  R.e.,  normal.  L.e.,  membrane  cloudy 
and  retracted,  in  places  thickened ;  around  the  umbo,  a  semi- 
lunar scar.    No  perforation  visible. 

Functional  examination:  Con.v.  2  —  3  m.  W.  1.,  R.  — ; 
Ci  -f,  C*  -f ,  both  sides  requiring  a  heavy  blow  to  the  fork 
to  make  it  audible.  No  spontaneous  ny.  Fistula  symp- 
tom -f,  reversed,  on  compression,  ny.  rotat.  r. ;  on  aspira- 
tion, ny.  rotat.  1. 

Aug.  31 :  Patient,  upon  his  request,  dismissed  without 
operatiop. 

7.  A.  Z.  Age  21.  Waiter.  Admitted  Oct.  10, 1908. 
Anamnesis :   Ten  years  ago,  following  scarlet  fever,  dis7 

charge  from  1.  ear,  lasting  about  one  year.  Treated  as  out- 
patient. Two  weeks  ago,  severe,  foetid  discharge  again  ap- 
peared. Headache  for  four  days.  Yesterday,  emesis  seven 
times,  with  attacks  of  vertigo.    To-day,  chills. 

Status  praesens:  R.e.,  normal.  L.e.,  drumhead  totally 
destroyed;  cholesteatoma. 

Functional  test:  Con.v.  0,  Whisp.v.  0,  no  tinnitus,  W.  r., 


108  DISEASES  OF  THE  LABYEINTH 

R.  — .  Bone  conduction  shortened.  Ci  0,  c^  0;  no  fistula 
symptom.  Cal.  react,  present,  witii  vertigo.  Temp.  40.2. 
Chills. 

Operation,  Oct.  11  (Prof.  Vrhantschitsch) :  Typical  radi- 
cal. Mastoid  sclerotic.  From  the  region  of  the  sinus,  gray- 
ish-green, foetid  pus,  mixed  with  gas  and  under  heavy 
pressure.  Exposure  of  sinus,  which  is  discolored  a  green- 
ish-yellow, and  is  perforated  at  one  point.  Ligation  of 
jugular.  Exposure  of  the  sinus  to  where  it  is  healthy,  and 
of  the  dura  in  front  of  and  behind  the  sinus.  The  thrombosed 
sinus  opened  and  cleaned  out  until  there  is  severe  bleeding 
from  above  and  moderate  hemorrhage  from  below. 
Dressing. 

Until  Oct.  15,  temp,  normal  and  condition  good. 

Oct.  15 :  Chills.  Temp.  38.9.  Packing  removed,  no  hem- 
orrhage. Jugular  sewed  after  Alexander's  method.  Irri- 
gation. Dura  of  posterior  fossa  covered  with  exudate. 
Sinus  groove,  visible.    Median  sinus  wall  discolored  yellow. 

Oct.  16:  Temp.  38.1. 

Oct.  17:  Temp.  37.5.  Dressing.  Temp,  from  now  on 
normal. 

Nov.  6 :  Transferred  to  O.P.  Dept. 

Feb.  12,  1909 :  Again  admitted. 

Anamnesis:  After  the  operation,  the  discharge  ceased  for 
six  weeks.  Eight  days  ago,  recurrence  of  the  discharge, 
with  pain  in  1.  ear  and  vertigo. 

Status  praesens:  Abundant  granulations  in  the  wound 
cavity,  but  they  do  not  prevent  a  view  of  the  deeper  parts. 
Region  of  the  semicircular  canal  epidermized. 

Functional  test:  Con.v.  3  m.,  whisp.v,  1  m.,  tested  with 
exclusion  apparatus;  I.e.  deaf  for  speech.  W.  1.,  R.  — . 
Bone  conduction  somewhat  lengthened.  Ci  and  c*  slightly 
perceived.  Past  two  days  no  vertigo.  Spont.  ny.  0.  Fis- 
tula symptom  -|-  and  reversed,  i.e.  on  compression,  rotat. 
ny.  1.    Cal.  ny.  typical. 

Both  sides  equally  syringed  25°,  ny.  1.  after  i/^',  and  after 
continuing  the  syringing  5'  no  change  in  the  1.  ny.  Patient 
says  he  is  not  dizzy  except  on  looking  to  the  1.    On  stop- 


CASE  HISTOEIES  109 

ping  the  syringing,  vertigo.  The  ny.  lasts  about  11/2'  longer. 
Temp,  normal. 

Feb.  13:  Temp,  normal. 

Feb.  14,  Temp.  38.2;  Feb.  15,  38.1;  Feb.  16,  36.2;  Feb. 
17,  38.1.  Granulations  removed.  Anaesthesia  with  20% 
cocain.    Because  of  pain,  complete  removal  impossible. 

Feb.  18,  Temp.  36.8;  Feb.  19,  38.4;  Feb.  20,  37.7;  Feb. 
21,  36.0;  Feb.  22,  38.0;  Feb.  23,  36.6;  Feb.  24,  37.3;  Feb. 
25,  38.2;  Feb.  26,  36.1;  Feb.  27,  37.7;  Feb.  28,  37.1.  From 
then  on  normal,  until  Mch.  4,  37.8,  when  there  was  an 
angina. 

Mch.  22 :  Transferred  to  O.P.  Dept. 

8.  J.  V.  Age  24.  Servant.  Admitted  Oct.  15, 1908. 

Anamnesis:  E.e.  discharged  in  childhood,  but  not  re- 
cently. Seven  weeks  ago,  patient  was  taken  with  pains  and 
noises  in  r.e.,  but  without  discharge.  Two  weeks  later  a 
swelling  appeared  behind  the  r.e.,  which  was  opened  by  his 
physician.    One  week  later,  discharge  appeared  from  ear. 

Status  praesens:  L.e.,  normal.  R.e.,  behind  the  ear  an 
adherent  scar  about  one  cm.  long.  No  swelling.  Quite 
abundant  creamy,  bad  smelling  discharge.  Large  perfora- 
tion in  ShrapnelVs  membrane;  the  rest  of  the  drumhead 
intact. 

Functional  test:  Hearing  distance  6  m.  (exclusion  ap- 
paratus left).  W.  in  head,  R.  — .  Sch.  lengthened,  Ci  short- 
ened, c^  shortened,  rotat.  ny.  1.  on  looking  to  1.  Fistula 
symptom  -\-,  typical.    No  vertigo,  no  tinnitus. 

Oct.  20,  Operation  (Bondy) :  Fistula  of  mastoid.  Choles- 
teatoma. Dura  of  both  fossae  extensively  exposed  and  cov- 
ered with  granulations.  Tip,  filled  with  granulations,  is 
resected.  Posterior  meatal  wall  removed  up  to  annulus 
tympanicus.  Lateral  attic  wall  removed.  Attic  cleaned, 
but  ossicles  left.  Now  there  is  visible  at  the  ampulla  of 
the  horizontal  semicircular  canal  a  small  circular  opening 
with  black  discolored  walls.  Upon  pressing  at  this  point 
with  a  sponge,  there  follows  a  slow,  rolling  movement  of 
the  eyes  to  the  healthy  side.    Plastic  after  Pause. 


110  DISEASES  OF  THE  LABYRIXTH 

Afternoon:  Temp.  36.8.  Patient  feels  comfortable.  No 
emesis  or  vertigo ;  slight  spontaneous  ny.  to  both  sides.  Pa- 
tient hears  con.v.  perfectly. 

Oct.  21:  No  pain,  vertigo  or  ny. ;  afebrile.  Con.v.  well 
heard  with  exclusion  apparatus  in  healthy  ear. 

Oct.  22:  Temp.  38.8.  First  dressing.  Wound  normal. 
Pressure  on  fistula  gives  active  ny.  to  diseased  side.  Con.v. 
perfectly  heard. 

Oct.  26:  Dressing.  Abundant  discharge,  somewhat 
foetid.  Wound  shows  granulation  begun.  Details  of  the 
tympanic  cavity  are  lost.  No  spontaneous  ny. ;  no  vertigo ; 
hearing  perfect.  Fistula  symptom  plainly  shown  by  pres- 
sure.   Light  packing. 

Nov.  4:  Fistula  symptom  still  present.  Cal.  react,  typi- 
cal. Some  spontaneous  rotat.  ny.  to  both  sides.  AVhisp.v. 
4  m. 

Nov.  10:  Discharged. 

Nov.  30 :  Inspected.  Attic  and  antrum  epidermized.  Fa- 
cial prominence  granulating.  Small  granulations  in  the 
horizontal  semicircular  canal.  Prompt  cal.  react.  Hear- 
ing: Whisp.v.  8  m.,  con.v.  12  m.    Fistula  sympt.  still  typical. 

9.  R.  O.   Age  20.  Admitted  Oct.  17,  1908. 

Anamnesis:  Chronic  suppuration;  increased  discharge 
during  past  eight  days.  Pains  in  head  and  mastoid  region 
at  intervals. 

Status  praesens:  L.e.,  normal.  R.e.,  cholesteatoma  in 
attic. 

Functional  test:  Con.v.  2i/2  m.,  whisp.v.  1  m.  W.  r.;  R.  — . 
Bone  conduction  shortened.  No  spont.  ny. ;  no  ny.  on  mov- 
ing head.    No  fist.  symp.    Cal.  ny.  typical.    Temp,  normal. 

Operation,  Oct.  17  {Bdrdny) :  Opening  of  antrum,  but 
preserving  the  tympanic  cavity.  Cholesteatoma  in  the 
antrum.    No  fistula  in  the  horizontal  canal. 

Oct.  18:  Temp.  38.2.    Dressing. 

Oct.  20:  No  fistula  symp.;  no  more  vertigo.  Slight  ny. 
to  diseased  side. 


CASE  HISTORIES  111 

Nov.  3:  Daily  dressing  until  now.  Much  discharge. 
Transferred  to  his  physician. 

Nov.  10:  Marked  fistula  sjTnptom;  occasionally  slight 
vertigo. 

Jan.  31,  1909:  Wound  cavity  entirely  epidermized.  Xo 
fistula  symptom.  Whisp.v.  6  m.  No  spontaneous  vertigo. 
Temp,  normal  since  first  change  of  dressing. 

10.  J.  G.   Age  17. 

Anamnesis :  Scarlet  fever  at  age  four.  In  eighth  year 
parents  first  noticed  that  child  did  not  hear  well,  particu- 
larly on  r.  side.  Oct.,  1908,  pain  in  1.  ear,  and  there  was  an 
*' abscess." 

Examined  recently  as  a  private  case  by  Dr.  Neumann, 
who  diagnosed  normal  caloric  reaction  and  turning  reac- 
tion on  both  sides.  Total  deafness  r.  Greath^  diminished 
hearing  1. 

Nov.  15,  1908:  I  Admitted  patient,  and  found  the  fol- 
lowing. R.  drumhead  cloudy  and  retracted,  scar  in  poste- 
rior superior  quadrant.  L.,  external  diffuse  otitis. 
Abundant  purulent  secretion.  Membrane  not  visible. 
Con.v. :  r.  0, 1.  0.  R.  totally  deaf  with  exclusion  apparatus 
and  conversation  tube.  L.,  words  shouted  ad  concham  were 
heard.  Also  loud  words  through  the  conversation  tube. 
W.  1. ;  Ci  not  heard  next  to  r.  ear,  but  heard  a  few  seconds  1. 
Bone  conduction  transmitted  from  r.  to  1.  side,  and  greatly 
shortened ;  c*,  both  sides  -f  when  the  fork  is  heavily  struck. 
Tested  with  the  continuous  tone  series,  c^  and  d^  heard  posi- 
tively; but  tested  with  Urbantschitsch's  harmonica,  all 
tones  (six  octaves)  are  heard  1.  Absolute  deafness  r.  Very 
marked  rotat.  ny.  r.  Cal.  r.  0  (carefully  tested  for  heat 
and  cold). 

The  ny.  increased  by  head  movements;  severe  vertigo 
with  every  movement.  Cannot  stand  without  help,  and  has 
to  be  held  in  chair.  L.  typical  fistula  symptom  with  quick 
component  1.  and  slow  component  r.  Turning  ny.  not 
demonstrable. 


112  DISEASES  OF  THE  LABYRINTH 

Because  of  vertigo,  patient  lias  to  be  tied  to  chair  for 
turning  test.    Complains  of  constant  tinnitus. 

Nov.  6:  Rotat.  ny.  to  r.  changes  in  intensity.  Severe 
vertigo  with  every  movement.  Patient  lies  more  upon  his 
right  side.  On  attempting  to  get  out  of  bed,  rotat.  ny.  r. 
ceases  a  short  time,  and  for  a  moment  severe  rotat.  ny.  1. 
appears,  soon  giving  way  to  rotat.  ny.  r.,  as  before. 

Repetition  of  tests  gives  result  as  yesterday.  Equilib- 
rium test  also  made  as  follows : 

With  head  straight,  falls  to  1. 

With  head  held  to  r.,  falls  forward. 

With  head  held  to  1.,  falls  backward. 

Fistula  symptom  present  like  yesterday,  but,  upon  pres- 
sure, there  occurs  a  ny.  to  1.  lasting  longer  than  the 
pressure. 

Galvanic  Ny. : 

Anode  to  r.  ear,  kathode  in  r.  hand,  no  noticeable  effect 
upon  the  spontaneous  ny. 

Kathode  to  r.  ear,  anode  in  r.  hand,  no  noticeable  effect 
upon  the  spontaneous  ny. 

Anode  to  1.  ear,  kathode  in  1.  hand,  no  noticeable  effect 
upon  the  spontaneous  ny. 

Kathode  to  1.  ear,  anode  in  1.  hand,  very  noticeable  rotat. 
ny.  to  1. 

Divided  anode  to  both  ears,  kathode  in  hand,  no  visible 
effect  upon  spontaneous  ny. 

Divided  kathode  to  both  ears,  anode  in  the  hand,  very 
plain  ny.  to  1. 

Direct  transmission,  kathode  to  r.  ear,  anode  to  1.  ear, 
rotat.  ny.  r.  apparently  stronger  even  with  eyes  directed 
forward. 

Anode  to  r.  ear,  kathode  fo  1.  ear,  rotat.  ny.  very  distinctly 
to  1.    Current  up  to  8  M.A. 

Nov.  17:  Totally  deaf  for  exclusion  apparatus,  for  con- 
versation tube  and  for  all  tones  of  the  continuous  series 
and  for  the  harmonica.  Fistula  symptom  no  longer  demon- 
strable. Severe  spont.  ny.  to  r.,  which  no  longer  changes,  and 
remains  the  same  in  all  positions  of  the  head.    Patient  does 


CASE  niSTOEIES  113 

not  complain  that  movements  of  the  head  cause  vertigo,  as 
on  the  first  daj'.  Cal.  react,  both  sides  O.  Turning  reaction 
both  sides  0.    Galvanic  reaction  0.    8  M.A. 

Nov.  18:  Totally  deaf.  Rotat,  ny.  as  before.  Vertigo 
decidedly  less.  Can  walk,  eats  without  nausea  or  emesis. 
Frequently  lies  upon  his  back.  Previously  wap  inclined  to 
lie  on  right  side.  Equilibrium  disturbances  typical,  i.e.  falls 
to  1.  with  head  forward.  With  head  to  1.,  falls  backward; 
falls  forward  with  head  turned  90°  to  r. 

Nov.  19 :  From  bass  f  to  c^  (harmonica)  traces  of  hear- 
ing remain.    The  same  Nov.  20. 

Nov.  21 :  Totally  deaf.  Cal.  react,  lost.  Spontaneous  ny. 
r.  still  large.  Typical  equilibrium  disturbances,  but  less 
marked.  Prefers  no  special  position  in  bed.  Complains  of 
head  noises. 

Nov.  23 :  Deaf.  No  reaction.  Galvanic  test  yields  no  re- 
sponse. Spontaneous  ny.  r.  decidedly  diminished.  Dis- 
turbances of  equilibrium  now  only  slight  but  typical. 

Typical  labyrinth  operation  1.  Immediately  after  opera- 
tion, no  severe  disturbances.  Moderate  emesis,  no  vertigo, 
only  pains.  Until  4  P.M.  (operation  was  at  12  M.),  anaes- 
thesia ny.  r.  and  1.    Then  ny.  r. 

11.  I.  M.  -cige  18.  Butcher's  helper.  Admitted  Nov. 
4,  1908. 

Anamnesis :  For  eight  years  occasional  discharge  1.  Dur- 
ing past  three  to  four  weeks,  pain  and  vertigo. 

Status  praesens:  L.,  total  destruction  of  drumhead. 
Granulations  and  cholesteatoma.  Con.v.  (with  exclusion 
apparatus)  1  m.,  whisp.  a.c.  W.  r.,  R.  — .  Bone  conduc- 
tion shortened,  Ci  0,  c*  0.  No  spontaneous  ny.  Bending 
head  backward  causes  ny.  r.  Fist,  symptom  -f,  but  re- 
versed, i.e.  compression  gives  severe  horizontal  ny.  r.,  and 
aspiration  weaker  i\j.  1.    Cal.  react,  typical.    Temp,  normal. 

Nov.  10:  In  view  of  the  hearing  and  reaction,  only  the 
radical  operation  was  at  first  performed.  The  dura  of  the 
middle  fossa  was  very  low,  a  large  cholesteatoma  occupied 
the  antrum,  and  there  was  a  fistula  in  the  horizontal  semi- 


114  DISEASES  OF  THE  LABYEIMH 

circular  canal.  During  the  following  days  there  was  fever, 
over  'SS~,  headache,  marked  ny.  to  the  healthy  side,  some 
rigidity  of  the  neck  and  sensitiveness  of  the  spine  upon 
pressure.  On  change  of  dressing,  patient  was  found  to  be 
totally  deaf  and  the  calor.  react  gone.  Thereupon  (Nov. 
13)  the  labyrinth  operation  was  performed  {Ruttin).  Neu- 
mann's method  was  followed,  and  because  of  the  rigidity 
of  the  neck,  the  operation  was  carried  to  the  internal  audi- 
tory meatus.  The  operation  was  especially  difficult  because 
of  the  position  of  the  dura.  Owing  to  the  admixture  with 
blood,  the  labyrinthine  fluid  could  not  be  examined.  The 
facial  nerve  after  the  operation  was  entirely  intact.  Dur- 
ing the  following  six  days,  reduction  of  fever,  pulse  about 
100,  subjectively  patient  was  comfortable.  Neck  no  longer 
sensitive  to  pressure.  Ny.  to  healthy  side.  On  the  seventh 
day,  suddenly  headache  appeared,  with  slight  ny.  to  the 
diseased  side.    Emesis.    Temp,  normal,  pulse  70. 

Nov.  20:  Patient,  in  the  forenoon,  is  apathetic;  notice- 
able ny.  to  diseased  and  healthy  side.  In  the  afternoon,  pa- 
tient is  better,  sits  up  and  plays  cards. 

Nov.  21 :  Pain  in  occipital  region,  neck  stiffly  held  with- 
out special  rigidity.    Ny.  1.  of  variable  intensity. 

Nov.  22 :  Occipital  headache.  Head  rigidly  held.  Apathy. 
Strong  ny.  1.  Lumbar  puncture  gives  clear  cerebro- 
spinal fluid.  Pulse  68.  Incision  of  the  cerebellum  in  the 
region  of  the  posterior  pyramidal  surface  empties  an 
abscess  nearly  the  size  of  a  plum  located  in  the  1.  cerebellar 
lobe.     Counter-incision  behind  the  sinus  and  drainage. 

Nov.  25:  Death. 

Postmortem  (Prof.  Stoerk) :  Abscess  of  1.  cerebellar 
hemisphere  completely  drained,  oedema  of  the  neighboring 
cerebellar  region,  hemorrhagic  encephalitis  in  the  corpus 
callosura,  severe  chronic  internal  hydrocephalus,  oblitera- 
tion of  convolutions,  no  meningitis.  Streptococcus  pyogenes 
in  the  pus. 

12.  H.  P.   Age  68,  Clerk.    Admitted  Oct.  15,  1908. 
Anamnesis :   Repeated  attacks  of  discharge  from  1.  ear 


CASE  HISTOBIES  115 

during  past  twenty  years.  Five  months  ago  a  swelling  ap- 
peared behind  the  1.  ear.  Vertigo  since  last  of  Sept.  Dur- 
ing past  day,  emesis  and  vertigo. 

Status  praesens:  Posterior  superior  meatal  wall  de- 
pressed. Membrane  red  and  swollen.  Perforation  not  visi- 
ble. Con.v.  a.c,  whisp.v.  0.  Middle  tuning  fork  not  heard 
next  the  ear.  Ny.  variable,  to  the  r.  and  1.,  regularly  rota- 
tory. On  bending  head  to  1.,  rotat.  ny.  to  1.,  and  on  indina- 
tion  to  r.,  weaker  nj'.  to  r.  Slightest  fistula  symptom.  Cal. 
ny.  very  severe  and  of  long  duration.    Temp,  normal. 

Operation,  Oct.  20  (Ruttin) :  Large  extradural  abscess 
of  posterior  fossa  extending  around  the  sinus.  A  fistula 
could  not  be  found. 

Oct.  21 :  Patient  feels  comfortable.  Temp,  normal. 
Pulse  106,  occasionally  intermittent.    No  ny. 

Oct.  22 :  A.M.,  very  marked  rotat.  ny.  to  r.  with  large 
excursion  of  eyeball,  for  all  positions  of  eyes.  Patient  lies 
on  the  r.  side.  Dressing  changed.  Patient  is  totally  deaf. 
W.  1.  Middle  tuning  fork  not  heard.  Low  fork  not  heard; 
c*  only  when  struck  hard.  Cal.  react,  elicited  plainly  by 
hot  saline  solution.  Marked  spontaneous  vertigo.  Emesis 
on  sitting  up. 

Oct.  22 :  Dressing  changed.  Cerebellar  dura  somewhat 
covered  with  exudate.  Kotat.  ny.  r.  with  eyes  to  r.  and 
forward.    Patient  lies  on  r.  side.    Vertigo  on  standing  up. 

Oct.  23 :  Ny.  to  r.  on  looking  to  r.,  but  not  on  looking  for- 
ward or  to  1.    Slight  vertigo  on  standing. 

Oct.  24 :  Dressing  changed.  Wound  as  above.  Cold  saline 
gives  typical  reaction.    Ny.  r.  with  eyes  in  every  direction. 

Oct.  25 :  Ny.  to  1.  Gait  wavering.  Vertigo.  Suspect 
cerebellar  abscess. 

Oct.  26:  Neurological  examination  (Dr.  Ekonomo) :  Noth- 
ing definite;  perhaps  a  trace  of  ataxia  of  the  lower  ex- 
tremities.   Fundus  normal  (Dr.  0.  Ruttin). 

Oct.  27:  Patient  suddenly  becomes  unconscious.  Weak 
tremor  of  r.  hand,  particularly  of  the  fingers.  Pupils  con- 
tracted, do  not  react.  No  ny.,  no  deviation.  Temp,  normal, 
pulse  120. 


116  DISEASES  OF  THE  LABYRINTH 

Operation,  with  patient  iiiiconscious,  without  anaesthetic 
(Ruttiii) :  Typical  hibyrinth  operation.  Incision  of  cere- 
bellum opposite  the  posterior  surface  of  the  pyramidal  bone. 
Abscess  emptied  of  several  tablespoonfuls  of  thick,  yellow, 
non-fetid  pus.  Counter-opening  back  of  sinus  and  drain- 
age. With  the  finger  in  the  cavity,  a  second  smaller  abscess 
located  more  to  the  rear  was  opened  and  drained.  About 
one  kour  after  the  operation  the  patient  returned  to  con- 
sciousness.   No  ny.,  pulse  104,  temp,  normal,  no  paresis. 

Five  hours  later  (11  P.M.),  we  have  the  following:  Eotat. 
ny.  to  r.  Pupils  react  slowly  to  light,  also  to  accommoda- 
tion. Eye  muscles  intact.  Corneal  reflex  active,  hoarse- 
ness, tongue  and  palate  not  coated,  laryngoscopic  exam,  im- 
possible. Thick  mucus  causes  cough.  Rough  breathing 
heard  over  lungs.  Temp,  normal,  pulse  104.  Patellar  re- 
flexes very  active.  Babinski  1.  clearly  positive.  Deep  re- 
flexes not  demonstrable.  Ataxia  of  the  1.  extremities,  par- 
ticularly of  the  upper  ones;  abdominal  reflex  and  cremas- 
teric reflex  1.  not  demonstrable,  r.  prompt.    Sensorium  clear. 

Oct.  28:  Neurological  exam.  (Dr.  Ekonomo),  results  like 
yesterday's,  only  the  patellar  reflex  is  weaker,  1.  weaker 
than  r.  Oppenheim  and  Babinski  1.  positive.  L.  corneal 
reflex  weaker  than  r. 

Oct.  29 :  At  5  A.  M.  patient  becomes  unconscious.  Eyes 
deviate  to  1.  Slight  ny.  impulses  to  r.  Pupils  small  and 
do  not  react.  Temp.  40,  pulse  104,  intermittent.  Dressing 
forceps  introduced  into  abscess  cavity  in  all  directions.  No 
pus.  Lumbar  puncture  yields  cloudy  fluid  under  slight 
pressure. 

Oct.  30:  Postmortem:  Diffuse  purulent  meningitis, 
drained  abscess  in  the  1.  cerebellar  lobe.  Streptococcus  mu- 
cosus  in  both  the  cerebrospinal  fluid  and  the  pus. 

13.  N.  H.  Age  27.  Admitted  from  the  Third  Medical 
clinic,  Sept.  8,  1908.    Advanced  phthisis.  , 

Anamnesis:  Presumable  only  during  past  three  months, 
discharge  r.,  beginning  with  pain.     The  pain  lasted  two 


CASE  HISTORIES  117 

weeks.  Never  vertigo.  Occasional  tiimitus,  like  escaping 
steam. 

Status  praesens:  L.e.,  normal.  E.e.,  perforation  anterior 
inferior  quadrant.  Granulations  in  the  tympanum,  which 
api^ear  below  the  upper  border  of  the  perforation. 

Functional  test:  Con.v.  0,  with  conversation  tube,  0. 
W.  r.,  E.  — ,  to  1;  Sch.  shortened;  Ci  0;  c*,  when  fork  is 
struck  with  metal,  is  perceived.  Fistula  symptom  very  pro- 
nounced and,  on  compression,  ny.  to  diseased  side  (very 
noticeable  ny.  caused  even  by  pressure  on  the  tragus). 
Aspiration  not  effective.    Cal.  react,  prompt. 

Nov.  10 :  On  arising,  some  vertigo.  Both  sides  irrigated, 
30°,  no  ny. ;  25°,  no  ny. ;  10°,  clear,  but  weak,  no  vertigo. 
R.  alone  10° ;  rotat.  ny.  1.  weak,  no  vertigo. 

Nov.  27 :  Fistula  symptom  present  just  as  above. 

l-:t.  N.  S.  Age  27.  Turner's  helper.  Admitted  Nov. 
14,  1908. 

Anamnesis:  Well  up  to  Apr.,  1907.  Then  had  "lung 
catarrh,"  at  the  same  time  there  appeared  noises  in  both 
ears,  which  ceased  after  two  days,  after  which  there  was 
decided  diminution  of  hearing.  R.  ear,  after  severe  pain, 
began  to  discharge.  Pains  ceased  when  the  discharge  be- 
gan. Since  then  the  ear  has  run;  no  other  symptoms  until 
Aug.,  1908,  when  attacks  of  vertigo  came  on.  Patient  could 
not  walk,  was  confined  to  bed  and  frequently  vomited. 

Status  praesens:  L.e.,  normal.  R.e.,  drumhead  totally  de- 
stroyed.   Fetid  discharge ;  cholesteatoma. 

Functional  test:  Con.v.  4i/4  m. ;  with  exclusion  apparatus 
(to  I.e.),  21^  m.  ;whisp.y.  (1.  ear  excluded),  i/^  m. ;  W.  r. ;  R.  — ; 
Sch.  lengthened ;  Ci  0,  c^  +.  At  the  present  time  no  tinnitus. 
Frequent  vertigo.  Cal.  ny.  prompt.  Typical  fist,  symptom. 
No  fever,  no  ny. 

Operation,  Nov.  14  (by  an  assistant) :  Mastoid  de- 
stroyed on  its  interior  and  filled  with  pus,  granulations  and 
small  sequestra.  Typical  radical  operation.  Pus  and  gran- 
ulations in  the  antrum,  no  ossicles.  Elongated  fistula  in  the 
horizontal  canal.    Disease  of  bone  extends  to  sinus,  which 


118  DISEASES  OF  THE  LABYIUXTn 

is  exposed.  Injured.  Hemorrhage.  Packing  applied. 
Various  cocci  in  the  mastoid.  Tubercle,  bacilli  not  found. 
5  P.M.,  emesis,  vertigo. 

Nov.  20:  Rotat.  ny.  r.  Vertigo;  facial  paresis;  hears 
through  dressing. 

Nov.  20  to  24:  Slow  decrease  in  vertigo.    Temp,  normal. 

Nov.  20:  Dressing.  Pus  in  the  tympanic  cavity,  other- 
wise healthy;  granulations.  Dressed  every  other  day. 
Never  any  fever. 

Dec.  2:  R.  side  total  deafness  for  speech  and  tuning 
forks.  Spont.  rotat.  n5\  1,,  not  very  marked.  Cal.  react, 
plain,  but  not  severe.  Patient  states  that  he  has  only  slight 
dizziness.  AV.  1.  Syringing  both  sides:  After  a  few  sec- 
onds rotat.  ny.  r.,  not  marked,  but  distinct.  At  the  same 
time  the  spont.  rotat.  ny.  1.  disappears.  Temp,  of  the  saline 
solution  21°.  Duration  5'.  During  the  entire  period,  no 
change  of  the  rotat.  ny.  r.  Equal  quantity  of  solution  used 
on  the  two  sides. 

Dec.  7 :   Discharged  to  O.P.  Dept. 

15.  F.  S.  Age  47.  Admitted  Jan.  25,  1909. 

Anamnesis:  Supposedly  always  well.  Four  months  ago, 
tickling  and  scratching  in  the  r.  ear,  without  any  discharge. 
Nine  weeks  ago  patient  noticed  that  there  was  a  discharge 
from  r.  ear,  which  appeared  without  preceding  pain,  when 
he  felt  perfectly  well.  Since  the  discharge,  repeated  attacks 
of  vertigo,  spontaneous  and  increased  by  applying  the  fin- 
ger in  the  meatus.  Rarely  frontal  headache,  more  on  right 
side.  Patient  has  coughed  for  years.  Occasional  tinnitus  r. 
Internal  report  (Dr.  Herz) :   Phthisis,  especially  1. 

Status  praesens:  L.e.,  normal.  R.e.,  perforation  anterior 
inferior  quadrant.    Posterior  superior  wall  of  canal  swollen. 

Functional  test:  With  exclusion  apparatus,  total  deaf- 
ness r.  Deaf  for  tuning  forks  r.  W.  in  the  head.  R.  — , 
heard  on  1.  side.  No  spont.  ny.  Fistula  symptom  +»  typi- 
cal. Cal.  react,  -f .  Syringing  both  sides,  25°,  rotat.  ny.  r. 
after  10",  continuing  during  5'  longer  syringing.  Quantity 
of  water  used  390  c.c.  for  each  side. 


CASE  HISTORIES  119 

Operation,  Jan.  27  (Prof.  JJrhantschitsch) :  Mastoid 
within  entirely  destroyed.  Typical  radical  operation. 
Some  sequestra  removed  from  antrum.  In  the  horizontal 
semicircular  canal  an  elongated  fistula,  several  millimeters 
in  length,  discolored  brownish-red,  and  having  sharp  edges. 
All  diseased  bone  removed.    Plastic. 

Jan.  28:  Patient  feels  comfortable.  Vertigo  only  upon 
standing.  Rotat.  ny.  1.,  large  movement  on  looking  to  1., 
small,  on  looking  straight  forward,  and  smallest  on  looking 
to  r.  Slightly  increased  on  sitting  up.  Patient  lies  upon 
back.    No  emesis. 

Jan.  29 :  No  ny.  lying  down.  No  vertigo,  only  slight  diz- 
ziness on  sitting  up.  During  the  entire  stay  in  hospital, 
regular  evening  rise  in  temp,  (tuberculosis). 

16.  E.  T,  Age  62.  Female.  Inmate  of  almshouse.  Ad- 
mitted Feb.  2,  1909. 

Anamnesis:  Discharge  during  past  half  year.  Frequent 
headaches.  Four  weeks  ago,  blood  in  discharge  from  ear. 
Then  patient  had  vertigo  for  first  time,  when  objects  seemed 
to  move  to  the  r.  Fourteen  days  ago  she  noticed  that  in 
the  morning  her  mouth  was  one-sided.  That  morning  she 
had  severe  vertigo.  She  staggered  on  walking,  and  took  to 
her  bed.  She  vomited,  and  stated  she  had  the  sensation  of 
being  in  the  water.  Since  then,  frequent  attacks  of  vertigo, 
when  objects  seem  to  turn  about  her.  At  first,  these  attacks 
were  less  frequent;  later,  more  often.    Frequent  tinnitus. 

Status  praesens:  Internal  and  neurological  findings  nor- 
mal. Facial  paresis  1.  R.e.,  normal.  L.e.,  total  destruction 
of  the  membrane.    Polyps  in  the  inner  wall  of  tympanum. 

Functional  test:  With  exclusion  apparatus,  deaf.  W.  r., 
R.  —  (transferred  to  sound  side).  Sch.  shortened.  No 
spontaneous  ny.  Cal.  react.  0.  Tr.  r.  =  horizontal  ny.  1. 
lasting  a  few  seconds.  Tr.  1.  =  horizontal  ny.  r.  15".  Tin- 
nitus and  vertigo.  Fistula  symptom  +  ;  on  pressure,  severe 
rotat.  and  horizontal  ny.  to  1.,  which  continues  during  the 
succeeding  aspiration.    Aspiration  alone  gives  no  reaction. 


120  DISEASES  OF  THE  LABYEIXTH 

Xy.  produced  by  simply  iutrodueing  the  tip  of  apparatus 
into  the  ear.  On  compression,  we  note  this  difference  from 
the  ordinary :  The  ny.  does  not  immediately  attain  its  maxi- 
mum of  intensity,  but  increases  for  several  seconds,  then 
gi'adually  subsides,  corresponding  to  an  attack  of  ny. 
Temp,  normal. 

Feb.  3,  Temp.  38.0;  Feb.  4,  normal. 

Feb.  4,  Operation  {Ruttin) :  Mastoid  pneumatic,  with  its 
cells  filled  with  granulations.  The  walls  in  part  necrotic. 
Typical  radical  operation.  In  the  horizontal  semicircular 
canal,  a  fistula  larger  than  a  pin-head  with  discolored  edges 
and  permitting  the  passage  of  the  labyrinth  sound.  Typical 
labyrinth  operation.  The  sinus  lying  well  posterior,  ex- 
posure of  the  dura  of  the  posterior  fossa  is  not  required. 
It  is  sufficient  to  open  the  vestibulum  from  behind,  without 
exposure  of  the  dura.  Many  cells  of  the  tegmen  antri  and 
tympani,  filled  with  granulations,  are  removed  with  the 
chisel.  Sinus  exposed  for  2  cm.  Its  wall  is  normal.  After 
the  operation,  in  the  evening,  emesis,  vertigo.  Temp,  now 
and  later,  normal. 

Feb.  5 :  Rotat.  ny.  r. ;  emesis,  vertigo,  nausea. 

Feb.  6:  Same. 

Feb.  7 :  Rotat.  ny.  r.,  less  vomiting,  headache,  lies  upon 
back. 

Feb.  8:  Rotat.  ny.  r.  less,  headache  better,  no  emesis, 
Haematoma  1.  lower  eyelid. 

Feb.  9:  Rotat.  ny.  r.  quite  marked.  Haematoma  the 
same.    Headache  less. 

Feb.  10:  Rotat.  ny.  r.  like  yesterday.  Feels  well.  Out 
of  bed.  First  change  of  dressing;  no  discharge.  "Wound 
bleeds,  slight  inflammation  of  edges  of  wound. 

Feb.  19:  Ny.  practically  gone.  Facial  as  before  opera- 
tion.   Transferred  to  O.P.  Dept. 

17.  M.  P.  Age  29.  Servant  girl.  Admitted  Feb.  14,  1909. 

Anamnesis :  Discharge  from  both  ears  since  scarlet  fever 
at  age  3.  Worse  recently.  Vertigo,  with  loss  of  conscious- 
ness.   Patient  cannot  recall  when  she  first  had  vertigo. 


CASE  HISTORIES  121 

Status  praesens:  E.e.,  total  destruction  of  the  drum  mem- 
brane. Inner  wall  covered  with  granulations.  Thin  fetid 
secretion  from  antrum.     L.e.,  polyp  obstructing  the  canal. 

Functional  test:  Con.v.,  r.,  I1/2  m.;  1.,  1/2  m.  Whisp.,  r., 
a.c;  1.,  0.  W.  r.,  R.  — .  Bone  conduction  lengthened  on 
both  sides;  Ci  r.  + ;  1.  — ;  c*  r.  +,  1.  — .  Now  no  vertigo. 
No.  spont.  ny.  Cal.  react,  prompt.  R.  fistula  sympt.  +, 
typical  on  compression,  with  rotat.  ny.  r.  Aspiration  gives 
no  clear  reaction.  Fistula  symptom  only  at  times  present. 
Temp,  normal. 

Operation,  Feb.  16  (Prof.  U  rb  ants  chit  sch) :  L.  typical 
radical  operation.  Nothing  of  special  interest.  R.  in  the 
antrum  granulations  and  pus.  In  the  horizontal  semicircu- 
lar canal,  a  small  semicircular  dehiscence,  not  admitting  a 
probe.    Temp.  37.7. 

Feb.  17  and  18 :  Patient  feels  well.  No  vertigo  or  head- 
ache.   No  ny.    Temp.  37.7,  37.8. 

Feb.  19-22:  Patient  feels  entirely  well.  Temp.  36.2, 
37.9,  37.0,  37.4. 

Feb.  23:  Temp.  37.9. 

Feb.  24:  Transferred  to  O.P.  Dept.    Temp.  36.7. 

18.  M.  Z.  Age  44.  Admitted  Feb.  16,  1909. 

Anamnesis:  Discharge  from  r.  ear  for  about  fifteen 
years.  1896,  polyps  were  removed  at  this  clinic.  Pains  dur- 
ing past  three  months.  During  past  month,  increased  puru- 
lent discharge  and  vertigo.  The  vertigo  comes  in  attacks, 
when  patient  always  falls  to  r.  Headaches  for  years,  in- 
creased p'ast  two  to  three  months.  Hearing  reduced  re- 
cently. Patient  has  always  heard  poorly  with  1.  ear.  Never 
any  discharge  from  this  ear.    Temp.  37.5. 

Status  praesens:  Feb.  17,  I.e.,  clouded  membrane,  greatly 
retracted.  R.e.,  abundant,  fetid,  purulent  discharge.  Ex- 
tensive destruction  of  membrane,  only  upper  portion  with 
short  process  and  small  part  of  hammer  handle  preserved. 

Ftmctional  test:  L.e.,  words  shouted  heard  a.c.  W.  in  the 
head;  R.  — ,  Sch.  shortened.  Ci  and  c^  much  shortened; 
spont.  ny.  0;  fistula  test  0.    R.e.,  deaf,  R.  — ;  Sch.  short- 


122  DISEASES  OF  THE  LABYRINTH 

ened ;  Ci  0,  c*  heard  only  by  striking  fork  with  metal.  Fis- 
tula test  +.  Cal.  react,  typical.  No  ny.  on  moving  head; 
severe  tinnitus  in  both  ears.  After  tr.  r.,  ny.  1.  15".  After 
tr.  ].,  ny.  r.  15".    Temp.  36.7. 

Feb.  18:  Syringing  both  sides,  25°,  rotat.  ny.  r.  very 
marked,  duration  about  2',  strong,  then  decreasing  for  5', 
when  syringing  is  stopped.  After  5'  some  rotat.  ny.  1.,  after 
6',  again  rotat.  ny.  r.,  weak;  during  the  syringing,  no 
vertigo. 

Operation,  Feb.  18:  Mastoid  sclerotic.  In  the  antrum, 
cholesteatoma  size  of  cherry.  In  the  horizontal  semicircu- 
lar canal,  an  area  2  —  3  mm.  long,  which  in  its  anterior  part 
is  a  permeable  fistula,  in  its  posterior  part  only  thin  canal 
prominence,  through  which  one  can  see  the  membranous 
canal.  Middle  fossa  exposed  to  less  than  size  of  a  one  heller 
piece.   Plastic.    Dressing.    Temp.  37.6. 

Feb.  19 :  Rotat.  ny.  r.  and  rotat.  ny.  1.  To  the  right  it  is 
more  of  a  ny.,  while  to  the  left  it  is  more  of  a  rolling  move- 
ment of  the  eyes,  with  equal  rolling  to  and  fro.    Temp.  37.2. 

Feb.  20:  Eye  movements  are  still  the  same.  Some  ver- 
tigo.   Temp.  36.3. 

Feb.  21 :  No  vertigo,  except  on  standing.    Temp.  37.3. 

Feb.  22 :  No  ny.    Temp.  37.5.    Normal  afebrile  course. 

Feb.  27:  Transferred  to  O.P.  Dept. 

June  14,  1909:  W.  in  head.  R.  — ;  Ci  0;  c'  0.  Tested 
with  exclusion  apparatus,  deaf.  L.  tr.  =  0.  R.  tr.  = 
marked  ny. 

Kathode  divided.    Anode  on  forehead 
=  rotat.  ny.  r.,  10  M.A. 

Anode  divided.    Kathode  on  forehead  ,    _    .. 
=  rotat.  ny.  1.,  10  M.A.  (    I^d^sP^table  and 

Anode  r.e.  4  M.A.  =  Rotat.  ny.  1.      /    very  accurately 

Kathode  r.e.  2  M.A.  =  Rotat.  ny.  r.      ^  *®^*®^- 

Kathode  I.e.  6  M.A.  =  Rotat.  ny.  1. 

Anode  I.e.  6  —  8  M.A.  =  Rotat.  ny.  r. 


CASE  HISTOEIES  123 

19.  A.  K.  Age  12.  School  child.  Admitted  Mch.  2,  1909. 
Anamnesis:  Not  obtainable. 

Status  praesens:  L.e. :  Membrane  totally  destroyed. 
Tympanic  cavity  mucous  membrane  granulating.  R.e. : 
Large  perforation,  cavity  wall  covered  with  granulations. 

Functional  test:  Con.v.,  r.,  4  m. ;  with  exclusion  appa- 
ratus, 1.,  1  m. ;  1.,  4  m. ;  with  exclusion  apparatus,  r.,  2  m. 
Whisp.,  r.,  1  m. ;  with  exclusion  apparatus  in  1.  ear,  a.c. ; 
1.,  1  m. ;  with  exclusion  apparatus,  l^  m.  W.  1.,  R.  r.  +  1.  — . 
Bone  conduction,  1.  shortened.  Ci  r.  and  1.  -|- ;  c^  r.  and  1.  +. 
No  vertigo.    No  spont.  ny.    Fistula  sympt.  typical. 

Operation,  Mch.  4  (Ruttin) :  Mastoid  pneumatic.  Cells 
behind  antrum  discolored.  Diseased  bone  extends  into 
posterior  fossa,  for  the  tegmen  antri  is  softened.  Typical 
radical.  In  the  horizontal  semicircular  canal,  a  fistula  about 
li/j  mm.  long,  closed  with  connective  tissue.  Tympanic  cav- 
ity and  tube  curetted.  No  ny.  in  the  evening  after  the 
operation. 

Mch.  5 :  No  ny.,  no  vertigo. 

Mch.  11:  Dressed.  Primary  healing  of  retro-auricular 
wound.  Sutures  removed.  Wound  bloody.  No  discharge. 
Plastic  in  good  order.  Hears  con.v.  y^  ^a.  (exclusion  appa- 
ratus).   Prompt  cal.  react,  with  vertigo. 

Up  to  Mch.  12 :  No  ny.  or  vertigo. 

Mch.  12:  Eotat.  ny.  r.  quite  large.     No  vertigo. 

Mch.  13:  As  above. 

Mch.  14 :  Rotat.  ny.  r.  less.    No  vertigo. 

Mch.  16:  Dressing.  Neurological  exam.  Con.v.  I/2  di. 
(exclusion  apparatus).    Prompt  cal.  react,  with  vertigo. 

20.  H.  P.  Age  47.  Office  helper.  Admitted  Mch.  15, 1909. 
Anamnesis:    Chronic  middle  ear  suppuration  of  years' 

standing.  Polyps  repeatedly  removed.  For  a  long  time, 
attacks  of  migraine  and  irritability.  Vertigo  only  during 
past  few  days. 

Status  praesens:   L.e.:  membrane  and  function  normal. 


124  DISEASES  OF  THE  LABYRINTH 

R.e. :  fetid,  purulent  dischnrg-e,  polyps,  cholesteatoma. 
Posterior  superior  meatal  wall  bulging. 

Functional  test:  Deaf  for  speech  and  tuning  forks.  W.  r., 
R.  — .  Sch.  shortened;  Ci  0,  c^  heard  when  struck  hard. 
Spont.  rotat.  ny.  =  1  (first  degree).  Fist,  sympt.  +,  and 
typical  (to  diseased  side  on  compression).  Caloric  test,  no 
response.    Temp.  39.1. 

Operation,  Mch.  15 :  Typical  radical  operation.  Ichorous 
cholesteatoma  in  antrum;  elongated  fistula  in  horizontal 
semicircular  canal.  From  the  region  of  the  sinus,  pus  un- 
der pressure  comes  out  with  pulsations.  Jugular  ligation. 
Exposure  of  sinus,  with  thorough  cleaning  of  thrombi  from 
the  bend  to  the  bulbus  jugularis.  Typical  labyrinth  opera- 
tion. 

During  the  succeeding  3-4  days,  rotat.  ny.  1.,  emesis  and 
vertigo. 

Because  of  a  continuance  of  the  fever,  on  Mch.  20,  the 
sinus  was  opened  further  backward,  some  thrombi  were 
removed  until  free  bleeding  was  secured.  After  a  further 
rise  of  temp.,  slow  defervescence,  and  patient  felt  tolerably 
comfortable. 

On  the  21st  day,  patient  became  unconscious  during  the 
night  and  died. 

Postmortem:  An  old  fetid  abscess,  4.5  x  4.5  cm.,  with  a 
pyogenic  membrane  2  mm.  thick,  in  the  r.  frontal  lobe  im- 
mediately in  front  of  the  precentral  fissure.  A  second  old 
abscess,  2.2  x  1.7  cm,,  with  thinner  membrane,  in  the  left 
parietal  lobe.  Circumscribed,  fetid  leptomeningitis  in  re- 
gion of  abscesses  and  of  the  r.  Sylvian  fissure ;  and  circum- 
scribed, in  part  adhesive,  internal  pachymeningitis  over  the 
larger  abscess.  Thrombophlebitis  of  the  r.  transverse  sinus 
and  the  sigmoid  sinus.  Opening  of  r.  transverse  sinus  in 
its  anterior  half  and  perforation  of  its  inner  wall  on  the 
border  between  the  opened  and  unopened  portions.  Cir- 
cumscribed, purulent  pachymeningitis  interna  in  the  region 
of  the  perforation  in  the  posterior  fossa.  Fatty  degen.  of 
the  parenchyma.     Adhesive  pleuritis,  particularly  r. ;  cal- 


CASE  HISTOBIES  125 

careous  degeneration  of  the  r.  apex.  Calcification  of  the  r. 
tracheo-bronchial  glands.  In  the  pus  of  the  abscess,  a  mix- 
ture of  different  germs. 

21.  A.  J.  Age  2G.  Worker  in  a  factory.  Admitted  Mch. 
19,  1909. 

Anamnesis :  In  Sept.,  1908,  pain  in  ear  and  tinnitus,  fol- 
lowed in  a  few  days  by  a  tenacious  purulent  discharge  from 
the  1.  ear,  which  continued  until  now.  From  Dec.  1,  1908, 
until  Jan.  1, 1909^  frequent  removal  of  polyps  and  curetting 
of  tympanic  cavity;  since  then,  frequent  vertigo,  occipital 
headache  and  nausea,  especially  in  the  morning. 

Status  praesciis:  R.e. :  membrane  and  function  normal. 
L.e. :  slight  swelling  of  superior  meatal  wall.  Pulsating  pus 
in  the  bottom  of  the  canal,  which  is  removed.  Drum  mem- 
brane red,  swelled,  perforation  in  anterior  inferior  quad- 
rant. 

Functional  test:  Mastoid  sensitive  to  pressure.  Deaf  for 
voice  and  tuning  forks.  W.  in  head.  R.  negative  (trans- 
mitted to  other  side).  Slight  spont.  ny.  to  both  sides.  Cal. 
react,  prompt.  Fistula  sympt.  -f ,  and  on  compression  the 
eyes  remain  in  position,  but  there  is  a  distinct  rolling  from 
lower  r.  to  upper  1.  of  interpalpebral  fissure.  Now  no  ver- 
tigo; continuous  tinnitus. 

Operation,  Mch.  20  (Bondy) :  Radical.  On  the  promi- 
nence of  the  horizontal  semicircular  canal,  an  area  look- 
ing suspiciously  like  a  fistula.  But  pressure  here  caused 
no  definite  eye  movement. 

On  the  third  day  after  the  operation,  spont.  ny.  alternat- 
ing between  the  two  sides.    Vertigo  and  emesis. 

Mch.  26 :  Dressing  changed ;  nothing  of  note.  Ny.  as  be- 
fore, but  weaker.  The  ny.  slowly  disappears  during  the 
following  days.  Intermittent  and  remittent  fever,  up  to 
39.7,  while  in  hospital. 

Patient  died  Apr.  21. 

Postmortem  (by  Prof.  Glion) :  Showed  chr.  tuberculosis 
involving  lungs  and  acute  miliary  tuberculosis  of  kidneys 


126  DISEASES  OF  THE  LABYRINTH 

and  Inngs.    Tubercular  disease  of  spine  and  psoas  abscess 
both  sides.    Lobar  pneumonia,  both  lower  lobes. 

22.  M.  R.  Age  41.  Cottager. 

Anamnesis:  Slight  discharge  and  tinnitus  for  four 
months.  During  past  three  months,  symptoms  have  in- 
creased, pain  and  greater  discharge.  One  month  ago,  facial 
paralysis  appeared.  Fourteen  days  ago,  sudden  vertigo, 
so  that  patient  found  it  difficult  to  avoid  falling.  Vertigo 
improved,  but  still  present.  Headache  only  at  time  of  se- 
vere pains  in  ears ;  no  nausea. 

Status  praesens:  Apr.  27,  1909.  L.e. :  membrane  and 
function  normal.  E.e. :  abundant,  very  fetid  discharge. 
Pulsation.  After  sponging:  Total  destruction  of  the  mem- 
brane. Marked  swelling  of  the  superior  and  posterior 
meatal  wall. 

Functional  test:  Deaf  for  tuning  forks  and  voice.  W.  1., 
spent,  rotat.  ny.  1.  on  looking  forward.  Cal.  react.  0.  Fis- 
tula sympt.  -f-,  with  very  severe,  large  rotat.  ny.  1.  on 
greater  pressure  (reversed  fistula  symptom),  with  marked 
vertigo  and  fainting  lasting  y2  minute ;  afterward,  headache 
in  the  r.  parietal  region.  Turning  ny. :  Tr.  1.  causes  no  visi- 
ble change  in  the  spont.  ny. ;  tr.  r.,  an  increase  in  the  ny. 
lasting  at  the  most  10''.    Total  facial  paralysis. 

Operation,  Apr.  27  (Bondy) :  Radical  operation.  An- 
trum and  mastoid  filled  with  caseous  masses,  bone  greatly 
softened.  Dura  of  middle  fossa  lies  exposed  over  an  area 
as  large  as  a  heller  piece,  covered  with  lardaceous  granu- 
lations. Labyrinth  in  its  entire  extent  necrotic.  Horizon- 
tal semicircular  canal  white  and  uncovered,  with  a  fistula 
permeable  for  the  labyrinth  probe.  Stapes  lies  free  in  the 
opening  of  the  oval  window,  with  the  niche  noticeably 
widened  and  deepened.  Promontory  also  uncovered.  The 
granulations  of  the  tympanic  cavity  extend  deep  backward 
into  the  inner  meatal  wall.  In  view  of  the  extensive  disease 
of  the  facial  prominence,  all  thought  of  saving  the  facial 
is  abandoned,  and  the  prominence  is  removed,   and  the 


CASE  HISTORIES  127 

nerve,  imbedded  in  granulations,  is  excised.  The  horizon- 
tal semicircular  canal  is  removed,  the  vestibule  is  widely 
opened  behind,  also  the  lateral  labyrinth  wall.  Cochlea  is 
cleaned.  Abundant  flow  of  labyrinthine  fluid.  Afternoon : 
Temp.  39.9.    Eotat.  ny,  1.  unchanged. 

Apr.  28:  A.M.,  temp.  —  38.0;  rotat.  ny.  1.  unchanged. 
P.M.,  ny.  disappeared. 

Apr.  30:  Patient  in  a  stupor.  Temp.  37.3;  pulse  60. 
Spont.  rotat.  ny.  to  diseased  side. 

Operation  {Bondy) :  Further  exposure  of  the  dura  of 
the  middle  fossa,  which  is  incised.  Brain  substance  dis- 
colored black.  Incision.  Large  amount  of  thin,  brown, 
fetid,  ichorous  fluid.  The  finger  introduced  shows  a 
smooth-walled  abscess,  the  median  and  posterior  wall 
reached  at  a  depth  of  4  cm.,  but  the  anterior  wall  cannot 
be  felt.  Eubber  drain.  Pulse  after  operation  120.  P.  M. : 
Patient  still  in  stupor,  but  responds  when  aroused.  Ny. 
gone. 

May  1:  Greater  stupor.    Complains  of  severe  headache. 

May  2 :  Stupor.  Eestlessness.  Rigidity  of  neck.  Coma. 
6  P.  M.,  death. 

Postmortem  (Erdheim) :  Large  r.  parietal  lobe  abscess 
opened  by  operation.  Pus  discolored,  bad  smelling,  con- 
taining pure  culture  of  micrococcus  meningitidis  intracellu- 
laris.  Abscess  wall  limited  by  pyogenic  membrane.  Col- 
lateral inflammatory  oedema  of  the  entire  r.  cerebellum. 
Free  leptomeningitis;  in  the  left  middle  fossa  there  is  in 
the  subdural  space  exudate  and  blood  from  the  operation. 
Chr.  tuberculosis  both  lungs,  with  extensive  ecchymosis  and 
tubercles.  Degeneration  of  the  parenchyma.  Extensive  tu- 
bercular ulcers  of  the  intestines. 

23.  H.  G.  Female.  Age  21.  Helper.  Admitted  Apr. 
4,  1909. 

Anamnesis :  Discharge  from  1.  ear  for  six  years.  Previ- 
ously treated  in  Wilhelmina  Hospital.  The  discharge 
diminished  at  times,  but  never  ceased.    Except  for  the  un- 


128  DISEASES  OF  THE  LABYRINTH 

pleasant  discharge,  patient  has  had  no  symptoms.  Four 
days  ago  she  had,  on  arising,  vertigo  and  vomiting. 
Vomitus  consisted  of  mucus  only.  At  the  same  time  she 
had  fever,  remained  in  bed  and  was  afraid  to  stand  up. 
Her  condition  became  worse  on  sitting  up.  This  continued 
four  days. 

Status  praesens:  L.e. :  In  the  external  canal,  very  fetid 
discharge  with  cholesteatoma ;  deeper,  granulations,  which 
bleed  easily.  Pus  pours  out  between  the  granulations.  The 
mastoid  region  in  general,  especially  over  the  sinus,  is  very 
tender,  even  without  pressure ;  also  the  jugular  region.  The 
patient's  general*  condition  is  bad;  she  vomits  repeatedly. 
Pulse  120;  temp.  38.8.    R.e. :  also  chr.  suppuration. 

Functional  test:  L.e.:  Con.v.  (with  exclusion  apparatus) 
36  —  40  cm.,  W.  1.,  R.  — ;  Sch.  lengthened  (not  dependable). 
Ci  and  c*  decidedly  shortened.  Vertigo  lying  upon  1.  side, 
very  marked  on  standing  or  sitting  up.  Spont.  ny.  chiefly 
r.  Fistula  sympt.  +.  Cal.  react,  typical.  Irrigating  both 
sides  gives  rotat.  ny.  1.  after  1'  with  no  change  during  10' 
flow.    850  c.c.  fluid  used  on  each  side. 

Radical  operation:  Very  early  in  the  operation,  thin  pus 
is  encountered.  After  opening  the  antrum,  which  is  filled 
with  granulations  and  cholesteatomatous  masses,  pus 
flows  out  from  behind  and  below  (pernicious  abscess). 
Sinus  exposed  for  a  short  distance.  Since  its  wall  is  sur- 
rounded by  pus  and  is  discolored  and  altered,  the  jugular 
and  facial  veins  are  ligated.  After  completion  of  the  radi- 
cal operation,  when  a  fistula  of  the  horizontal  semicircular 
canal  was  found,  the  sinus  is  followed,  and  must  be  exposed 
to  the  jugular  bulb,  and  to  within  three  finger  breadths  of 
the  median  line.  After  reaching  healthy  sinus  wall  and 
healthy  dura  in  the  middle  and  posterior  fossae,  both  being 
opened  over  a  large  area,  the  sinus  is  opened.  In  spite  of 
severe  hemorrhage,  the  sinus  is  thoroughly  inspected  and 
several  thrombi  removed.  After  free  bleeding,  packing. 
Hemorrhage  is  arrested.  Entire  wound  cavity  is  packed 
with  iodoform  wick;  closure  with  silk.    Plastic  postponed. 


CASE  niSTOEIES  129 

Apr.  5,  temp.  36.4;  Apr.  6,  37.9;  Apr.  7,  36.6;  Apr.  8,  37.9; 
Apr.  9  to  12,  norma] ;  Apr.  12,  37.8 ;  Apr.  13,  38.1 ;  from  Apr. 
14,  normal.  In  the  pus  from  the  mastoid  was  found  bac. 
proteus  (contamination). 

Apr.  12 :  First  dressing.    Wound  granulating. 

Apr.  14:  Dressing,  on  account  of  elevation  of  temp,  on 
13th,  when  a  bone  splinter  the  size  of  a  heller  piece  was  re- 
moved from  the  region  of  the  tip.     Temp,  fell  to  normal. 

Apr.  21 :  Discharged.  The  ligatures  of  both  the  central 
and  peripheral  stumps  were  not  removed.  Returns  for 
dressings. 

June  14,  Control  test:  Con.v.  (with  exclusion  apparatus 
r.)  i/o  m.,  nliddle  fork  well  heard  at  the  meatus.  W.  1.,  R.  — ', 
Sch.  lengthened.  Spont.  ny.  rotat.  r.  =  rotat.  1.  Cal.  react, 
(cold)  gives  distinct  ny.  rotat.  r.,  not  very  large,  with  no 
vertigo. 

24.  F.  S.  Age  28.  Admitted  Apr.  14,  1909. 
Anamnesis:     Advanced    pulmonary    tuberculosis.      L.e. 

operated  Aug.,  1908,  at  the  Poliklinik.  Then  there  was  dis- 
charge for  three  weeks.  Did  not  cease  after  operation. 
Tinnitus  1.  from  beginning  of  sickness.  Vertigo  only  dur- 
ing past  six  weeks,  when  hearing  has  also  been  poor. 

Functional  test:  R.e.,  normal  L.e.  (tested  with  exclusion 
apparatus),  deaf.  "\V.  in  head.  R.  -\-.  Sch.  greatly  re- 
duced. Middle  fork  at  ear,  0 ;  Ci  0 ;  c^  0.  Spont.  ny.  rotat. 
r.  =  rotat.  1.  Fistula  sympt.  +,  with  large,  slow,  rolling 
movement  to  r.  on  compression,  to  1.  on  aspiration.  Syr. 
b.s.  (25°),  after  Vo'  ny.  rotat.  1.,  with  severe  vertigo,  which 
ceases  during  syringing,  but  the  rotat.  ny.  1.  persists  during 
5'  irrigation,  variable,  but  distinct.  After  irrigation,  ver- 
tigo and  ny.  increased.  Ny.  after  tr.  r.  =  1.  horizontal  19" ; 
after  tr.  1.  =  ny.  horizontal  r.  28". 

25.  K.  G.    Age  30.  Draftsman.  Admitted  May  3, 1909. 
Anamnesis:    Discharge  both  sides,  first  in   1893,  with 

diminished  hearing,  so  that  he  was  dismissed  from  military 


130  DISEASES  OF  THE  LABYRINTH 

school.  Hearing  changed,  being  poorer,  first  on  one  side, 
then  on  the  other.  Says  he  had  no  discharge  then  and  is  not 
conscious  that  he  has  any  now.  Tinnitus  since  1893.  Does 
not  recall  previous  vertigo.  About  two  years  ago  had  ver- 
tigo for  first  time.  Then  liis  condition  improved,  and  in 
1900  was  able  to  perform  his  military  service  for  three 
years.  Since  1905,  condition  worse,  i.e.  loud  tinnitus  and 
attacks  of  vertigo,  chiefly  in  warm  weather  and  on  bicy- 
cling. Supposedly  no  discharge,  no  headache,  no  emesis. 
Eecalls  no  sickness.    Family  history  negative. 

Examined  (as  out-patient)  Apr.  22, 1909.  R.e. :  Chr.  sup- 
puration.   L.e. :  Chr.  adhesive  process. 

Functional  test:  Con.v.  r.  1  m. ;  1.  7  m.  Whisp:  r.  10  cm.; 
1.  13/^  m. ;  with  exclusion  apparatus  to  I.e.  con.v.  r.  10  cm. 
W.  r.,  R.  both  sides  — ;  Sch.  both  sides  lengthened.  Air 
conduction  for  middle  fork  r.  greatly  shortened ;  1.  less  so. 
c^  r.  perceived  only  on  being  struck  with  metal ;  1.  on  slight 
stroke.    Ci  both  sides  with  moderate  stroke. 

Spont.  rotat.  ny.  r.  =  1.  Fistula  symptom :  Compression, 
slow,  rolling  movement  to  1. ;  aspiration,  slow,  rolling  move- 
ment to  r.  No  ny.  After  the  fist,  test,  spont.  ny.  is  much 
stronger.  Syr.  b.s.  25°  =  rotat.  ny.  r.  after  II/2  minutes, 
the  irrigation  lasting  41/2  minutes.  No  change  in  ny.  350 
c.c.  fluid  used  on  each  side.    Fixator  adjusted  r.  20  and  1.  35. 

R.e.  alone  (25°),  rotat.  ny.  r.  slight,  yet  plain,  after  i/^', 
and  remains  nearly  constant  during  4'  irrigation.  L.e. 
alone,  after  1/2'?  plain  rotat.  ny.  r.  (stronger  than  r.),  in- 
creasing in  intensity  for  li/^',  then  about  the  same  for  5' 
irrigation. 

Divided  anode  —  kathode  to  forehead  =  rotat.  ny.  1.  not 
marked,  but  plain,  20  M.A. 

Divided  kathode  —  anode  to  forehead  =  rotat.  ny.  r. 
plain,  14  M.A. 

Kathode  r.  —  anode  to  forehead  =  rotat.  ny.  r.  8  M.A. 

Anode  r.  —  kathode  to  forehead  =  rotat.  ny.  1.  12  M.A. 

Anode  1.  —  kathode  to  forehead  =  rotat.  ny.  r.  10  M.A. 

Kathode  1.  —  anode  to  forehead  =  rotat.  ny.  1.  10  M.A. 


CASE  HISTORIES  131 

June  18,  1909:  Hearing  distance  (tested  with  exclusion 
apparatus) :  Conv.v.  10  cm.  W.  r.;  middle  fork  near  ear, 
shortened,  but  heard  relatively  long.  Sch.  not  shortened, 
rather  lengthened.  K.  — ,  Ci  with  moderate  exciting  stroke, 
c''  when  excited  with  the  finger  nail.  Fistula  symptom  still 
present,  on  compression  a  slow,  rolling  movement  to  the 
1.;  on  aspiration,  slow,  rolling  movement  r.  Caloric  test 
made  w4th  ether  apparatus:  Rotat.  ny.  1.  plain,  with 
vertigo. 

Status  praesens:  May  3,  1909.  L.  e. :  membrane  greatly 
retracted.  E.e. :  meatus  large,  containing  purulent  frag- 
ments. Membrane  reddened,  atrophic  area  surrounds  the 
hammer,  which  is  movable  (with  the  pneumatic  speculum), 
but  the  rest  of  the  membrane  appears  to  be  adherent.  No 
perforation  visible.  Above  and  posterior  to  the  hammer, 
masses  of  epidermis,  which  are  removed  with  difficulty. 

Functional  test:  L.e. :  Con.v.  7  m. ;  whisp.  li/^  m.  W.  r. ; 
R.  — ,  Sch.  lengthened.  Ci  and  c^  shortened.  Fist,  react.  0 ; 
Cal.  test,  prompt.  R.e. :  Con.v.  5  m. ;  whisp.  14  ni-;  K-  — > 
Sch.  lengthened.  Ci  and  c*  shortened.  Fist,  test  +,  Cal. 
react,  prompt.  Spont.  ny.  r.  on  looking  to  r.,  1.  on  looking 
to  1.     Tinnitus  1. 

Operation  {Ruttin) :  Mastoid  sclerotic.  Antrum  small 
and  contracted,  containing  a  few  granulations.  Dura  over 
tegmen  antri  exposed,  for  the  only  diseased  area  in  the 
antrum  appears  to  be  in  the  tegmen.  Dura  normal.  Typi- 
cal radical.  Facial  ridge  is  deeply  removed  to  expose  the 
tympanic  cavity,  for  the  suspected  fistula  in  the  horizontal 
canal  is  not  found,  and  the  canal  appears  perfectly  normal. 
Tonogen  applied.  Inspection  of  the  inner  tympanic  wall. 
Promontory  normal.  But  in  the  recess  of  the  oval  window 
appears  a  granulation,  on  which  is  a  portion  of  the  stapes. 
This  is  removed  and  is  found  to  consist  of  the  head  and 
half  of  one  crus  of  the  stapes.  Pressure  over  the  round 
and  oval  windows  produced  only  indefinite  rolling  move- 
ments of  the  eves. 


132  DISEASES  OF  THE  LABYIUXin 

After  tJic  operatiou,  4  P.]\I. :  Rotat.  ny.  r.  and  1.,  tlie 
1.  greater  than  the  r.    No  vertigo. 

9  P.M. :  Eotat.  ny.  r.  and  1.,  that  to  1.  greater  than  that 
to  r.  Some  vertigo  on  sitting  up,  when  there  is  only  rotat. 
ny.  1. ;  some  vertigo  when  patient  looks  to  1.  Emesis  three 
times.    Feels  comfortable. 

May  6:  Rotat.  ny.  1.  greater  than  r.  The  ny.  is  greater 
in  the  abducted  eye  than  in  the  adducted  eye,  and  greater 
on  looking  to  the  extreme  right  than  to  the  extreme  left. 
Some  vertigo  on  sitting  up. 

May  7 :  Rotat.  ny.  1.  greater  than  r.,  but  less  than  yes- 
terday.   No  vertigo. 

May  8:  Slight  rotat.  ny.  1.  greater  than  r.    No  vertigo. 

May  10 :  Rotat.  ny.  1.  =  r.,  very  slight.    Goes  about. 

May  11 :  First  change  of  dressing.  Wound  in  good  con- 
dition. Hears  (with  exclusion  apparatus)  Con.v.  y^  i^- 
"VV.  r.  Middle  fork  heard  a  long  time  by  r.  ear.  Ci  and  c^ 
r.  4--  Cal.  react,  (cold  water)  very  prompt.  Spont.  ny.  r. 
=  1.  rotat.  and  very  slight.  Fist,  test  not  made,  because 
of  pain. 

May  13 :  Transferred  to  O.P.  Dept. 

26.  E.  M.  Age  30.  Male.  Admitted  May  18,  1909. 

Anamnesis:  Discharge  from  r.  ear  from  youth,  occasion- 
ally ceased;  continuous  for  past  three  years.  Five  weeks 
ago,  attacks  of  vertigo  after  removal  of  polyp  from  r.  ear. 
Vertigo  less  during  past  few  days.  Occipital  headache. 
Nausea  past  two  days. 

Status  praesens:  R.e..  Total  destruction  of  drum. 
Granulations.    L.e. :  Normal. 

Functional  test:  R.e.:  Con.v.  l^  m.;  whisp.  0.;  W.  r., 
R.  — ,  Sch.  lengthened.  Ci  +  c*  +.  No  spont.  ny.,  no  fis- 
tula sympt.    Cal.  react,  typical;  no  fever. 

Operation,  May  19  [Ruttin) :  Large  cholesteatoma,  fill- 
ing entire  mastoid.  Typical  radical  operation.  Dura  of 
middle  and  posterior  fossae  exposed  and  covered  with  gran- 
ulations.   Parts  of  the  cholesteatoma  invade  the  capsule  of 


CASE  HISTORIES  133 

the  labyrinth.  Curettage.  A  fistula,  2-3  mm.  long,  discol- 
ored, in  the  horizontal  semicircular  canal. 

May  20:  Temp.  38.5.  Ny.  rotat.  1.  not  strong;  slight  ver- 
tigo. 

May  21 :  Temp.  37.4,  38.4.  Rotat.  ny.  1.  decidedly  greater, 
some  vertigo,  otherwise  patient  is  comfortable.  Hears  loud 
voice  through  dressing. 

May  22 :  Rotat.  ny.  1.  the  same.  Slight  vertigo.  Temp. 
37.5. 

May  23 :  Rotat.  ny.  1.  slight.  No  vertigo.  Patient  walks 
about.    Temp,  from  now  on  normal. 

May  24 :  Rotat.  ny.  1.  slight. 

May  25 :  As  above.     Dressing. 

May  29:  Dressing.  Deaf  for  speech  and  tuning  forks. 
No  cal.  react.  W.  1.,  when  fork  is  placed  in  mastoid  process, 
localized  to  r. 

June  1 :   Transferred  to  O.P.  Dept. 

27.  F.  K.  Age  9.  Admitted  May  27,  1909. 
Anamnesis:  Discharge  following  measles  at  six  months. 

L.e.  operated  in  fourth  year.  Two  years  ago,  scarlet  fever, 
since  which  time  discharge  also  from  r.e. 

Status  praesens:  Conv.v.  10  cm.  (with  exclusion  appa- 
ratus 1.).  Cal.  react,  -f.  Fistula  sympt.  +,  on  compres- 
sion greater  ny.  r.,  on  aspiration  lesser  ny.  1.    Temp.  38.0. 

Operation  [Bdrdny) :  Cholesteatoma  in  antrum.  Pus 
from  sinus  region,  which  is  surrounded  with  pus.  Its  wall 
discolored.  Emissary  vein  thrombosed.  Sinus  does  not 
bleed  on  removal  of  the  vein.  Near  the  ampulla  of  the  an- 
terior semicircular  canal  there  is  apparently  a  fistula,  from 
which  or  from  its  vicinity  there  is  venous  hemorrhage, 
which  is  stopped  by  tonogen.  Sinus  incised  and  thrombi 
removed.  Jugular  vein  not  ligated,  because  of  the  charac- 
ter of  the  fever.    Normal  healing. 

28.  H.  R.  Admitted  Apr.,  1909.  Advanced  pulmonary 
tuberculosis. 


134  DISEASES  OF  THE  LABYRINTH 

Anamnesis:  Discharge  r.  ear  since  Aug.,  1908.  No  tin- 
nitus or  vertigo. 

Status  praesens:  R.e.,  normal.  L.e.,  chr.  middle  ear  sup- 
puration. 

Functional  test:  L.e.  deaf.  W.  r.  R.  — .  Sch.  not  short- 
ened. Ci  and  c^  0.  Typical  fistula  symptom.  Both  sides 
irrigated  (25°),  ny.  rotat.  1.,  without  vertigo.  Cal.  react., 
each  side  separately  tested,  gives  a  good  reaction. 

Galvanic  test  positive. 

29.  Th.  A.  Age  25.  Female.  Admitted  June  3,  1909. 

Anamnesis:  R.e.  always  healthy.  Six  years  ago,  with- 
out previous  pain,  deafness  in  1.  ear.  Discharge,  though 
slight,  persisted  until  now.  Since  Jan.,  1909,  severe  pains 
and  abundant  discharge.  No  vertigo,  no  emesis,  now  and 
then  headache. 

Status  praesens:  R.e.:  membrane  normal.  L.e.:  canal 
narrowed.  Posterior  superior  wall  decidedly  swollen,  ob- 
scuring drum.    Abundant  pus. 

Functional  test:  Loudest  speech?  W.  in  head.  R.  — . 
Sch.  shortened?  Ci  and  c^  0.  No  spont.  ny.  Fistula 
sympt.  -f-.  Cal.  react.  O.  No  vertigo,  no  tinnitus.  Temp. 
37.6. 

Operation,  June  3  (Prof.  Urb  ants  chit  sch) :  After  push- 
ing periosteum  aside,  it  .was  seen  that  the  entire  posterior 
meatal  wall  was  absent.  Through  this  defect,  w^hich  in- 
volved also  the  surface  of  the  mastoid  bone,  a  cholesteatoma 
was  visible.  The  thin  contex  removed.  Removal  of  the 
cholesteatoma,  which  filled  the  entire  mastoid  and  extended 
to  the  dura  of  the  middle  and  posterior  fossae.  Severe 
hemorrhage  from  the  middle  fossa  and  from  the  further 
exposure  of  the  posterior  fossa;  also  from  the  mastoid 
emissary  vein.  The  entire  inner  bony  area  is  movable,  and 
is  taken  out  as  a  sequestrum,  which  is  interspersed  with 
the  cholesteatoma  and  which  shows  cholesteatomatus  lamel- 
lae on  its  dural  surface.  Jugular  bulb  is  thus  exposed.  Its 
bleeding  controlled' by  packing.    The  resulting  defect  ex- 


CASE  HISTORIES  135 

tends  forward  to  the  promontory.  The  sequestrum  eon- 
tains  parts  of  the  semicircular  canals. 

June  3:  Complete  facial  paralysis.  Increasing  uncon- 
sciousness. Hyperaesthesia  of  the  skin.  Eigidity  of  the 
neck.    Temp.  40.0,  38.2,  39.4. 

June  4:  Lumbar  puncture  gives  cloudy  fluid  containing 
many  grampositive  streptococci.  Dura  over  cerebellum  in- 
cised, results  in  an  emptying  of  retained  subdural  pus.  In- 
cision of  the  cerebellum  yields  no  pus.  Temp.  38.8,  39.6, 
36.8. 

June  5:   Death,  in  the  midst  of  deep  coma.    Temp.  40.0. 

Postmortem:  Acute  purulent  leptomeningitis  on  the  base 
and  convexity  of  brain.  Pus  in  the  subdural  space  of  the 
posterior  fossa ;  canal-like  defect  in  the  left  cerebellar  lobe 
from  probing.  Diffuse  tuberculosis  healing  in  both  upper 
lobes  and  at  tip  of  1.  lower  lobe.  Hemorrhages  into  the 
pleural  cavity,  adhesions  of  upper  lobes.  Parenchymatous 
degeneration  of  internal  organs.  Purulent  angina,  both 
sides. 

30.  J.  L.   Age  30.   Female.   Admitted  June  12,  1909. 

Anamnesis:  L.e. :  normal.  R.e. :  discharge  of  three 
months'  duration,  without  any  pain.  Since  the  middle  of 
May,  severe  vertigo  on  inserting  finger  into  r.  ear.  No  spont. 
vertigo.  Now  and  then  headache.  Tuberculosis  of  spine 
and  old  hip  joint  disease. 

Status  praesens:  L.e.:  normal.  R.e.:  fetid  suppuration. 
Polyps. 

Functional  test:  Conv.v.  4  m.,  whisp.  i/o  na.  W.  in  head. 
R.  — .  Sch.  lengthened;  Ci  shortened;  c*  shortened;  no 
tinnitus,  no  spont.  ny.,  no  vertigo.  Fistula  sjonpt.  -f ,  typi- 
cal, with  falling  to  the  diseased  side  on  compression. 
Symptom  elicited  even  by  pressure  on  the  tragus.  Irriga- 
tion with  cold  water  (without  pressure)  causes  slight,  but 
distinct  ny.  L,  without  vertigo,  but  only  after  prolonged 
application. 


136  DISEASES  OF  THE  LABYRINTH 

Kathode  divided  —  anode  to  forehead  =  rotat.  ny.  r., 
4  M.A. 

Anode  divided  —  kathode  to  forehead  =  rotat,  ny  1., 
2  M.A. 

Anode  right  —  kathode  to  forehead  =  rotat.  ny.  1.,  1  M.A. 

Anode  left  —  kathode  to  forehead  =  rotat.  ny.  r.,  4-5 
M.A. 

Kathode  right  —  anode  to  forehead  =  rotat.  ny.  r.,  2/10 
M.A. 

Kathode  left  —  anode  to  forehead  =  rotat.  ny.  1.,  5-6 
M.A. 

Operation,  June  16  (Prof.  U  rb  ants  chit  sch) :  Typical  rad- 
ical. Cholesteatoma  in  antrum.  In  the  horizontal  semi- 
circular canal,  located  forward,  a  large,  discolored  fistula, 
pressure  upon  which  causes  slow,  extensive  movement  of 
the  eyes  to  the  healthy  side. 

June  16 :  Spont.  rotat.  ny.  1.  slight.    Some  vertigo. 

June  17:  Temp.  37.0.  Ny.  to  healthy  side,  not  strong, 
but  larger  than  yesterday.    Some  vertigo. 

June  18:  Temp.  37.2.  Ny.  to  healthy  side,  slight.  No 
vertigo.    About  noon,  feels  well. 

June  19 :  Temp.  37.8.    No  ny. ;  no  vertigo. 

June  20:  As  above.     Temp.  36.2. 

June  21:  In  the  evening,  sudden  vertigo.  Rotat.  ny.  1. 
of  third  degree.  No  headache.  Temp.  37.4.  Dressing 
changed.  Wound  clean.  Pressure  on  the  semicircular 
canal  causes  no  ny.  and  no  vertigo.  Hears  (without  exclu- 
sion apparatus  applied  to  1.  ear)  con.v.  14  m.  Cal.  react, 
typical,  but  slight  and  without  vertigo.  W.  r.,  R.  heard  to 
1. ;  c*,  when  fork  is  struck  with  metal.    Ci  0. 

June  22  and  23:  Rotat.  ny.  only  on  looking  to  1.  No 
vertigo. 

June  24 :  Rotat.  ny.  1.  only  on  looking  to  1.  Dressed.  No 
vertigo. 

June  28:  Transferred  to  O.P.  Dept. 

July  14.  Patient  has  vertigo  when  ear  is  cleaned.  Fis- 
tula symptom  still  present.    Cal.  react,  weak,  but  typical. 


CASE  HISTORIES  137 

Aug.  5:  R.e.  entirely  dry,  epidermized.  W.  r.,  R.  r.  — . 
Air  conduction  for  C  nearly  normal.  Ci  +,  c*  +.  Hearing 
distance  for  con.v.  =  2  m. ;  whisp.  a.c.  Fistula  symptom 
present.  Caloric  test  +.  Turning  ny.  after  tr.  1.  =  hori- 
zontal r.  16  oscillations  in  15''.  After  tr.  r.  =  ny.  horiz.  1. 
30  oscillations  in  25".  Div.  anode  (6  M.A.),  no  ny.  (No 
further  galvanic  test  possible.) 

31.  M.  P.  Age  23.  Maid.  Admitted  June  14,  1909. 

Anamnesis :  1905,  after  typhoid,  suppuration  r.  ear.  Dis- 
charge continuous,  but  not  treated.  Since  June  1,  frequent 
attacks  of  vertigo,  recurring  often.  No  headache,  no 
emesis. 

Status  praesens:  L.e. :  normal.  R.e.:  canal  filled  with 
polyps.    Drumhead  entirely  destroyed. 

Functional  test:  Conv.v.  30  cm.  W.  in  head.  R.  — . 
Sch.  lengthened.  Ci  and  c*  decidedly  shortened.  Cal.  ny. 
prompt.  Fistula  symptom  -f-.  Spont.  ny.  rotat.  and  to 
both  sides. 

Examination  June  17:  Fistula  s\Tnptom  typical;  com- 
pression, ny.  r.  clearly  rotatory,  quite  strong;  on  aspira- 
tion, the  reverse.  Irrigation  of  both  ears  (25°),  after  i^', 
ny.  rotat.  r.  R.e.  only  irrigated  with  cold,  giving  prompt 
reaction.    No  vertigo. 

Turning  reaction: 

After  tr.  r.,  ny.  horizontal  1.,  21  movements  in  20". 

After  tr.  1.,  ny.  horizontal  r.,  13  movements  in  16". 

Repeated : 

After  tr.  r.,  ny.  horizontal  1.,  33  movements  in  35". 

After  tr.  1.,  ny.  horizontal  r.,  30  movements  in  25". 

Operation,  June  17  (Bondy) :  Typical  radical.  Many 
granulations  in  antrum  and  mastoid.  Dura  of  parietal  lobe 
exposed,  for  the  softening  extends  to  the  dura.  Fistula  in 
the  horizontal  semicircular  canal  running  obliquely  from 
the  outer  posterior  portion  inward.  Pressure  here  pro- 
vokes no  eve  movement. 


138  DISEASES  OF  THE  LABYRINTH 

June  18 :  Ny.  rotat.  r.  =^  ].  No  vertigo.  Lies  on  back. 
Temp.  37.7. 

June  19:  Ny.  rotat.  r.  =  1.  Since  yesterday,  the  rota- 
tory ny.  1.  is  stronger.    J^o  vertigo ;  temp,  normal. 

June  20:  Ny.  rotat.  1.     No  vertigo. 

June  21:  Ny.  rotat.  ].  (only  first  degree). 

June  22 :  Ny.  rotat.  1.  In  the  evening,  vertigo  and  head- 
ache. Temp,  normal.  First  dressing.  Deaf  for  spoken 
voice.    Caloric  react.  -{-,  typical. 

June  23:  Ny.  rotat.  1.  (1st  degree).    No  vertigo. 

June  24:  Ny.  rotat.  1.  =  r.  only  on  looking  to  r.  and  1. 
Vertigo  only  on  standing  suddenly. 

June  25:  As  above. 

June  28 :  Transferred  to  O.P.  Dept. 

32.  E.  L.  Age  32.  Merchant.  Admitted  June  17,  1909. 

Anamnesis :  One  year  ago,  I  removed  polyps  from  r.  ear, 
and  after  two  months  of  conservative  treatment  the  ear  be- 
came dry.  One  month  ago  he  returned  with  a  recent  an- 
trum suppuration.  When  operation  was  proposed,  patient 
quit  treatment.  June  11,  he  had  a  sudden  attack  of  ver- 
tigo with  emesis,  and  could  not  hold  himself  in  the  upright 
position.    June  15,  I  was  called  into  consultation. 

Status  praesens:  E.e. :  fetid  suppuration.  Patient  is  pale 
and  emaciated.  Marked  spont.  rotat.  ny.  to  r.  Fistula 
symptom  typical,  on  compression,  rotat.  ny.  to  r. 

Functional  test:  Hears  shouted  words  a.c.  Also  hears 
the  middle  fork  at  the  ear.    W.  r.    Ci  and  c*  0. 

June  16:  Vomited  entire  day.  Frequent  eructations. 
Hears  conv.v.  Vo  m.  (which  is  better  than  on  11th  inst.). 
Fistula  sympt.  as  before.  Strong  spont.  ny.  rotat.  r. 
Pulse  52. 

June  17 :  Patient  feels  better ;  has  vomited  less,  vertigo 
less,  nausea  less.  Pulse  72.  Spont.  rotat.  ny.  1.  decidedly 
stronger,  being  present  in  whatever  direction  patient  looks. 
Patient  says  he  feels  better,  and  has  less  vertigo  when  he 
looks  to  r.    R.e.  irrigated  with  cold  water,  after  a  long  time 


CASE  HISTORIES  139 

reacts  with  some  doubt ;  no  vertigo.    Hearing  Vo  m.  as  be- 
fore.   Tuning  fork  as  above. 

Operation,  June  17  (RnUin) :  After  pushing  aside  the 
meatus,  there  appears  a  fistula  in  the  lateral  antrum  wall 
out  of  which  flows  pus,  which  pulsates.  The  entire  mastoid 
is  changed  into  a  cavity  occupied  by  a  putrid  cholesteatoma. 
Typical  radical  operation.  In  the  antrum,  a  sequestrum 
involves  the  tegmen.  The  sinus  and  the  dura  of  the  poste- 
rior fossa  are  laid  bare,  also  the  dura  of  the  middle  fossa. 
This  is  markedly  thickened  and  covered  with  granulations. 
'  Fistula  in  the  horizontal  semicircular  canal,  2  mm.  long, 
not  discolored.  Typical  labj^rinth  operation.  Abundant 
flow  of  fluid  from  labyrinth.  Parietal  lobe  incised.  In  pene- 
trating the  dura,  there  is  a  sensation  of  entering  a  vacant 
space,  and  only  at  a  depth  of  2  cm.  is  the  healthy  brain  sub- 
stance felt.  No  brain  prolapse,  in  spite  of  a  good  pulsation 
and  an  opening  in  the  dura  about  li/^  cm.  long. 

June  18:  Eotat.  ny.  1.    Vomiting  and  vertigo.    Pulse  52. 

June  19 :  Eotat.  ny.  1.     Pain  in  the  wound. 

July  8:  Slight  pain  and  headache  in  the  region  of  the 
vertex  r.  Less  ny.  Transferred  to  O.P.  Dept.  Never  any 
fever. 

33.  K.  G.  Age  15.  Comb-maker's  apprentice.  Admitted 
July  26,  1909. 

Anamnesis :  Had  radical  operation  1.  at  another  clinic  one 
yr.  ago.  Discharge  continued.  During  past  two  weeks, 
headache  on  1.  side  and  attacks  of  vertigo,  which  often  recur. 

Status  praesens:  E.e. :  Scars.  Function  normal.  L.  e. : 
Cavity  of  radical  operation  filled  with  granulations.  Eetro- 
auricular  wound  not  closed. 

Functional  test:  Conv.v.  a.c.  With  exclusion  apparatus 
to  r.  e.,  deaf.  W.  r.  E.  — .  c^  and  Ci  0.  Fistula  symptom 
now  0,  but  was  present  one  month  ago.  Caloric  ny.  prompt. 
No  fever  during  two  weeks  in  hospital. 

Operation,  Aug.  9  (Ruttin) :  Cavity,  filled  with  scars  and 
granulations,  is  cleaned  out.    In  the  posterior  fossa  lies  the 


140  DISEASES  OF  THE  LABYRINTH      . 

dura,  and  perhaps  the  siims.  There  is  so  much  alteration 
from  scars  that  details  cannot  be  distinguished.  These 
structures  lie  so  far  foi'ward,  so  close  to  the  facial  promi- 
nence, that  there  is  little  room  for  the  labyrinth  operation. 
Typical  labyrinth  operation.  A  granulation  over  the  oval 
window,  which  admits  the  probe  with  almost  no  resistance. 
Promontorium,  which  is  very  soft,  is  removed  with  chisel. 
The  probe,  introduced  backward,  emerges  in  the  tympanic 
cavity.  After  the  operation,  rotat.  ny.  r.  of  third  degree. 
Lies  on  right  side.  No  fever.  Feels  well,  except  for 
vertigo. 

Aug.  10:  Eotat.  ny.  r.,  severe  emesis  and  vertigo,  espe- 
cially on  attempting  to  sit  up.    Temp,  normal. 

Aug.  11:  Rotat.  ny.  r.  Emesis  like  yesterday.  Temp, 
normal. 

Aug.  12 :  Rotat.  ny.  r.  and  horizontal  ny.  1.  no  longer  so 
great.  No  emesis  since  yesterday  noon.  No  vertigo,  even 
on  sitting  up.    Temp,  normal. 

Aug.  13 :  Feels  well.  No  vertigo.  Rotat.  ny.  r.  and  hori- 
zontal 1.  slight.  In  the  night,  patient  complains  of  head- 
ache.   Temp,  normal. 

Aug.  14:  Temp.  38.4.  Headache.  Restless.  Ophthal- 
moscopic exam.  (Dr.  0.  Ruttin) :  Slight  neuritis  1.  (I  was 
out  of  Vienna  on  this  day,  and  saw  the  patient  on  Aug.  15.) 
Operated  at  once :  Dura  of  posterior  fossa  exposed  over  a 
large  area.  Nowhere  was  a  wound  of  the  dura  found,  ex- 
cluding any  possibility  of  a  causal  factor  in  the  first  opera- 
tion. In  the  opened  labyrinth,  a  drop  of  pus.  Since  the 
lumbar  puncture  made  previous  to  this  operation  showed 
cloudy  fluid  and  contained  many  pus  cells  and  single  strep- 
tococci, I  made  a  wide  incision  in  the  dura  of  the  posterior 
fossa,  and,  suspecting  a  cerebellar  abscess,  I  also  incised  the 
cerebellum,  but  with  negative  results. 

Aug.  15:  Temp.  40^ 

Aug.  16:  Death. 

Postmortem  (Prof.  Ghon) :  Diffuse,  purulent  basal  lepto- 
meningitis,   particularly    over    the    cerebellum.      In    the 


CASE  niSTOFIES  141 

cerebrospinal  fluid  and  in  the  exudate  of  the  meningitis, 
streptococcus  pyogenes. 

34.  K.  M.  Age  20.  Locksmith's  helper.  Admitted  Aug. 
11,  1909. 

Anamnesis:  Since  childhood,  suppuration  r.  ear.  No 
vertigo. 

Status  praesens:  Granulations  and  bad  smelling  dis- 
charge r.    Swelling  over  the  mastoid.    Temp.  38.3. 

Functional  test:  Conv.v.  (exclusion  apparatus  1.)  2  m. 
Spont.  ny.,  alternating  r.  and  1.  Fistula  sympt.  +,  typical. 
Caloric  react,  weak. 

Operation  {Bar any) :  Radical  operation.  Cholesteatoma 
in  antrum.  Fistula  in  horizontal  semicircular  canal.  Sinus 
laid  bare.  Emissary  vein  thrombosed.  Diagnostic  punc- 
ture into  sinus.    Bleeds  freely.    Packing. 

Aug.  12:  Temp.  38.0.  Ny.  rotat.  1.  Hears  loud  voice 
through  bandage. 

Aug.  14:  Temp.  37.3. 

From  Aug.  14  on,  normal  course. 

Aug.  19 :  Heard  con.v.  through  dressing. 

35.  G.  S.    Age  26.    Female.    Admitted  Sept.  11,  1909. 

Anamnesis:  Very  deaf  and  a  foreigner.  Statements  ob- 
tained through  a  relative.  Supposedly  a  *' tumor"  in  r.  ear, 
operated  five  or  six  years  ago.  Since  then  headache.  Dur- 
ing past  twenty  days  pains  have  been  unbearable.  Recently 
disturbances  of  equilibrium,  vertigo,  and,  since  last  night, 
emesis. 

Status  praesens:  Both  ears  chr.  suppuration  with  choles- 
teatoma. 

Functional  test :  R.e. :  conv.v.  1  m. ;  whisp.  %  m. ;  W.  r., 
R.  — ,  Sch.  leng-thened.  Ci  and  c*  +.  No  spont.  ny.  Calor. 
react,  typical.  Fistula  sympt.  +.  Compression,  ny.  rotat. 
r.;  aspiration,  ny.  rotat.  1.  (weaker).  After  tr.  r.,  horizon- 
tal ny.  1.  =  30";  after  tr.  1.,  horizontal  ny.  r.  =  30".  Ny. 
to  r.  more  rapid. 


142  DISEASES  OF  THE  LABYRLSTll 

Operation,  Sept.  17  {Ruttin) :  The  first  blow  of  the  chisel 
exposes  a  cholesteatoma,  filling  the  mastoid  and  lying  upon 
the  sinus,  and  filling  also  the  antrum.  A  fistula,  2  mm.  long, 
in  the  horizontal  semicircular  canal,  permeable  for  the  laby- 
rinth probe,  with  dark-colored,  sharply  defined  edges.  The 
ossicles  not  present.  Evening:  Vertigo,  vomiting.    No  ny. 

Sept.  18 :  Vertigo,  emesis.    No  ny.    Temp.  37.6. 

Sept.  19 :  Emesis ;  no  ny. 

Sept.  23:  Feels  comfortable.  No  spont.  ny.  Dressing, 
Conv.v.  1  m.,  whisp.  I/2  i^i.  With  exclusion  apparatus  1. : 
Conv.v.  Yo  m.    Whisp.  0.    Wound  in  good  condition. 

Sept.  28 :  Transferred  to  O.P.  Dept. 

Sept.  29:  Functional  test  gives  same  results  as  on 
Sept.  23. 

36.  H.  D.  Age  20.  Cashier.  Female.  Admitted  Sept. 
20,  1909. 

Anamnesis:  L.e.  discharged  for  four  yrs.  During  past 
eight  days,  swelling  and  redness  of  skin  over  zygoma.  Dur- 
ing past  two  days,  vertigo  on  moving  rapidly.  Fever. 
Headache. 

Status  praesens:  R.e. :  Dry  perforation.  Obstructive 
deafness.  L.e. :  Perforation  in  posterior  superior  quadrant. 
Granulations  from  antrum. 

Functional  test:  Conv.v.  7  m.  Whisp.  %  m.  W.  1.,  R.  — , 
Sch.  lengthened.  Ci  0,  c*  +.  Spont.  ny.  rotat.  r.  =  ny. 
rotat.  1.  Fistula  sympt.  -f ;  aspiration  =  ny.  vertical  up- 
ward and  rotat.  r.  Compression  =  ny.  vertical,  upward 
and  rotat.  1.  On  aspiration,  the  ny.  is  at  first  stronger,  then 
equal  to,  the  ny.  of  compression.  After  several  tests,  there 
is  greater  spont.  ny.  to  both  sides.  A  horizontal  component 
is  entirely  absent.    Cal.  react,  prompt  and  very  marked. 

Tr.  r.  =  after  ny.  horizontal  1.   24  movements  in  25". 

Tr.  1.   =  after  ny.  horizontal  r.  60  movements  in  35". 

Operation,  Sept.  22  (Prof.  Urbantschitsch) :  Granula- 
tions  in   antrum.     Typical   radical.     Careful   inspection. 


CASE  HISTORIES  143 

Horizontal  canal  smooth,  no  visible  fistula.  Normal  course, 
no  fever. 

Sept.  26:  Transferred  to  O.P.  Dept. 

Second  admission,  July  14,  1910.  After  first  operation 
there  was  no  more  vertigo.  But  the  discharge  continued. 
Could  not  take  regular  treatment.  Frequent  headaches,  but 
felt  well  until  three  days  ago.  Then  had  severe  pains  in  r. 
ear,  with  free  discharge  from  1.  ear.  Severe  headache  and 
vertigo.    No  emesis. 

Status  praesens:  L.e. :  Retro-auricular  scar.  Radical 
operation.  Meatus  wide.  Upper  and  middle  portions  of 
cavity  well  covered  with  epidermis.  In  inferior  anterior 
part,  free  pus.  Mastoid  not  sensitive  to  pressure.  R.e. : 
Membrane  retracted  and  thickened,  reddish-yellow.  A  drop 
of  pus  on  Shrapnell's  membrane.   Perforation  not  visible. 

Functional  test:  R.e.:  Con.v.  2  m.  Whisp.  ?  Tested 
with  exclusion  apparatus :  Con.v.  30  cm.  L.e. :  Con.v.  3  m. 
Whisp.  ^  m.  With  exclusion  apparatus :  Con.v.  i/o  m.  Tin- 
nitus 1.  W.  in  head.  R.  — ,  both  sides.  Sch.,  both  sides 
lengthened.  Middle  fork  well  heard  at  ear.  Ci  and  c^  both 
easily  perceived.  Spont.  ny.  r.  on  looking  to  r.  Fistula 
sympt.  r.  negative,  1.  positive,  but  on  compression  no  ny.; 
on  aspiration,  ny.  rotat.  r.  strong,  with  vertigo.  Compres- 
sion with  Valsalva  gives  no  ny.    Caloric  react,  prompt. 

Tr.  r.  =  after  ny.  horizontal  1.  23  movements  in  17". 

Tr.  1.  =  after  ny.  horizontal  r.  42  movements  in  22." 

No  vertigo  from  turning  in  either  direction. 

July  24 :  Upon  her  request,  patient  is  discharged. 

37.  J.  J.    Age  24.    Coachman.    Admitted  Oct.  16,  1909. 

Anamnesis:  As  long  as  he  can  recall,  1.  ear  has  dis- 
charged and  he  has  had  attacks  of  vertigo.  Two  to  three 
years  ago,  had  frontal  headaches  once  or  twice  a  day.  One 
month  ago,  pains  in  the  ear,  nausea  without  vomiting,  head- 
ache more  severe.  One  week  ago,  headache  so  severe  he 
was  forced  to  lie  down.  Since  then,  vertigo  on  turning  his 
head  and  tinnitus. 


144  DISEASES  OF  THE  LABYEIXTH 

Status  praesens:  E.e. :  normal.  L.e. :  membrane  totally 
destroyed.    Granulations. 

Functional  test:  Con.v.  0.  W.  in  head.  E.  — ,  Sch.  short- 
ened. Ci  0 ;  c^  +•  Fistula  sjTaptom  +  ;  compression  gives 
first  a  deviation  of  the  eyes  to  r.,  then  a  ny.  rotat.  r. ;  with 
aspiration,  the  reverse,  but  stronger. 

Tr.  r.  =  after  ny.  horizontal  1.  36  movements  in  25". 

Tr.  1.  =  after  ny.  horizontal  r.  19  movements  in  24". 

No  fever.    Spont.  rotat.  ny.  r. 

Operation,  Oct.  26  (Prof.  Urbantschitsch) :  Radical  op- 
eration. Granulations  in  the  antrum.  Mastoid  sclerosed. 
Horizontal  canal  apparently  intact,  but  on  closer  inspection 
there  is  on  the  side  toward  the  labyrinthine  nucleus  a  fis- 
tula permeable  for  the  labyrinth  probe. 

Oct.  27:  Dressing.  Ny.  rotat.  r.  still  marked.  Course 
without  fever. 

Oct.  28 :  Ny.  rotat.  r.  still  strong.    No  vertigo. 

Oct.  29 :  Totally  deaf.  Cal.  react.  0.  Spont  ny.  rotat.  r. 
No  vertigo. 

Nov.  11 :  Ny.  rotat.  r.  still  present  on  looking  to  r.  Had 
no  pain  or  vertigo,  he  says,  after  operation.  Feels  exceed- 
ingly well.  Before  the  operation  he  had  at  times  diplopia. 
Wound  granulating  well.  W.  r.,  R.  — .  (Ci  0,  transmitted 
to  other  ear.  C  0,  c''  transmitted  when  hit  hard.)  Left  e. 
totally  deaf. 

Tr.  r.  =  after  ny.  horizontal  1.  10  movements  in  14", 
weak,  some  vertigo. 

Tr.  1.  =  after  ny.  horizontal  r.  31  movements  in  24", 
marked,  severe  vertigo. 

Divided  kathode,  anode  to  forehead  =  ny.  rotat.  r.,  6 
M.A.,  very  plain  and  stronger  than  spont.  ny. 

Divided  anode,  kathode  to  forehead  =  ny.  rotat.  1.,  10 
M.A.,  very  weak,  and  the  existing  spont.  rotat.  ny.  r.  does 
not  disappear. 

38.  J.  W.  Age  36.  Laborer's  helper.  Admitted  Nov. 
2,  1909. 


CASE  HISTORIES  145 

Anamnesis :  Discliarge  I.e.  since  childhood.  During  past 
two  weeks,  pain  and  increased  discharge.  During  past  two 
days,  vertigo.    Fever  for  one  day. 

Status  praesens:  Chronic  suppuration  both  ears.  K. 
canal  filled  with  granulations.  Mastoid  not  swelled,  but  tip 
sensitive  to  pressure.  In  the  jugular  region,  near  the  angle 
of  the  jaw,  a  cord-like  resistance  which  is  not  painful. 

Functional  test :  R.e. :  Con.v.  10  cm.  Whisp.  0.  AVith  ex- 
clusion apparatus  applied  1.,  deaf.  W.  r.,  R.  — ,  Sch.  not 
lengthened.  Ci  0,  c*  +  when  struck  hard.  Fistula  symp- 
tom + ;  compression  =  ny.  rotat.  1.  (to  healthy  side) ;  aspi- 
ration =  ny.  rotat.  r.  (diseased  side) ;  i.e.  reversed  fistula 
symptom.  Spont.  ny.  of  very  slightest  degree  to  both  sides. 
L.e. :  Con.v.  4  m.  Whisp.  V/2  ni.  Staggering  gait.  Falling 
to  rt.    Dizziness.    Temp.  40.2. 

Operation  (Bondy) :  Ligation  of  the  unaltered  blood- 
containing  jugular.  Radical  operation.  Granulations  in 
antrum.  Horizontal  canal  prominent,  noticeably  white, 
with  a  crater-like  fistula,  with  irregular  walls  and  filled  with 
granulations  in  its  posterior  portion.  Pressure  here  pro- 
duces slow  movement  of  eyes  to  the  diseased  side.  Poste- 
rior to  the  antrum,  dura  of  cerebellum  and  sinus  discolored. 
Sinus  laid  bare  from  its  upper  bend  to  the  bulb,  until  nor- 
mal portion  is  reached.  Since  normal  dura  could  not  be 
found,  the  typical  labyrinth  operation  was  performed. 
Twitching  of  face  muscles  when  granulations  are  removed. 
Thrombosed  sinus  cleaned  out. 

Nov.  3:  Facial  paralysis.  Ny.  rotat.  to  healthy  side. 
Temp.  36.7.    Patient  comfortable. 

Nov.  5:   Ny.  entirely  gone. 

Nov.  6:  Dressing. 

Nov.  9 :  No  ny.  on  looking  in  different  directions.  Some 
ny.  behind  opaque  spectacles. 

Nov.  22:  Transferred  to  O.P.  Dept.  Temp,  to  Nov.  8, 
37.8  to  38.1.    Since  then,  normal. 


146  DISEASES  OF  THE  LABYEIMH 

39.  O.  D.  Age  30.  Stationmaster.  Admitted  Nov.  8, 1909. 

Anamnesis:  Ear  trouble  r.  for  20  vrs.  Practically  no 
suppuration.  Hammer  fixed  to  promontory.  Cholestea- 
toma in  antrum. 

Functional  test:  Con.v.  1/2  m.  W.  1.,  K.  — ,  Sell,  short- 
ened, Ci  — ,  c^*  — .  No  spont.  ny.  Cal.  react,  prompt.  Typ- 
ical fistula  sympt.  Both  sides  irrigated  23°,  5',  ny.  rotat. 
r.  very  plain,  with  some  vertigo;  r.  225  c.c,  1.  200  c.c.  (no 
response  r.),  irrigator  held  low. 

Tr.  r.  =  after  ny.  horizontal  1.  34  movements  in  25". 

Tr.  1.  =  after  ny.  horizontal  r.  14  movements  in  10". 
On  repeating  this  test,  decidedly  less  ny.  on  tr.  1. 

Standing  with  closed  eyes,  well  done,  but  stands  better 
with  eyes  open.     (Falls  in  no  particular  direction.) 

Standing  upon  r.  foot,  falls  to  r. 

Standing  upon  1.  foot,  falls  to  1. 

"Walking  with  eyes  open  or  shut  is  well  done  both  for- 
ward and  backward ;  turning  the  head  has  no  influence. 

Kathode  divided,  anode  to  forehead  =  ny.  rotat.  1.,  dis- 
tinct. 

Anode  divided,  kathode  to  forehead  =  ny.  rotat.  r.  dis- 
tinct. 

Nov.  11 :  Fistula  react,  obtained  by  touching  tragus.  Cal. 
react,  r.  (23°)  gives  at  once  rotat.  1.,  as  if  it  were  hyper- 
sensitive; 1.  (23°)  appears  slightly  later  than  r.,  with  ny. 
rotat.  r.    Temp,  normal. 

Operation,  Nov.  11  {Euttin) :  Cortex  hard.  Large  cells 
behind  facial  and  at  tip,  filled  with  discolored  pus.  Typi- 
cal radical.  A  very  broad  and  long  (4  mm.?)  fistula,  in- 
volving nearly  all  of  the  horizontal  canal.  Bone  diseased 
to  the  sinus,  which  is  normal.  Evening:  Rotat.  ny.  1.  quite 
marked.    Vertigo  on  looking  to  1.,  otherwise  comfortable. 

Nov.  12 :  Morning,  ny.  rotat.  1.  weaker,  and  with  less  ver- 
tigo on  looking  to  1.  No  change  on  sitting  up.  Hears 
through  dressing  14  i^i*    Temp.  37.3. 

Nov.  13 :  Ny.  rotat.  1.  on  looking  to  1.    Goes  about. 

Nov.  14:  Ny.  rotat.  1.  on  looking  to  1.    Temp.  37.6. 


CASE  HISTORIES  147 

Nov.  15:  Ny.  rotat.  1.  less.  Hears  througli  dressing. 
Temp.  37.2. 

Nov.  16:  Condition  same.  Ny.  rotat.  1.  slight.  Temp, 
normal. 

Nov.  17 :  A.M.,  vomited  twice.  Ny.  rotat.  1.  in  every  po- 
sition of  the  eyes.  Slight  vertigo.  Goes  about  at  noon. 
Dressing.  Eetro-auricular  wound  nearly  closed,  beginning 
granulations.  R.e.  totally  deaf  (f).  W.  r.,  E.  — ,  Sch. 
shortened,  Ci  0,  c^  0,  a^  fork  heard  for  a  moment.  Cal.  re- 
act, weak,  with  vertigo. 

Nov.  18 :  A.M.,  emesis  once.  Generally  comfortable.  Ny. 
rotat.  1.  quite  strong,  of  2nd  degree.  Vertigo  on  sitting  up. 
Evening,  rotat.  ny.  1.  3d  degree.    Vertigo.    Temp.  37.8,  38.1. 

Nov.  19:  Better.  No  emesis.  Ny.  rotat.  1.  only  when 
looking  to  the  left  and  forward.  No  vertigo  on  turning, 
only  weakness.  Temp.  37.4.  Dressing.  Primary  closure 
of  wound.  Hears  (with  exclusion  apparatus  1.)  loud  speech 
a.c,  decidedly  better  than  day  before  yesterday.  He  him- 
self observes  it.  W.  r.,  R.  — .  Sch.  slightly  shortened.  Mid- 
dle fork  heard  at  ear.  a^  10".  Ci  0,  c^  when  struck  hard. 
No  reaction  with  hot  saline  irrigation.  Fistula  sympt.  -|-, 
easily  provoked,  very  plain  compression  ny.  rotat.  r. ;  aspi- 
ration ny.  rotat.  1.  weaker,  with  vertigo.  Temp,  henceforth 
normal. 

Dec.  13:  Following  findings:  No  more  spont.  ny.,  but 
present  on  dressing.  Typical  fistula  symptom  and  vertigo 
on  touching  region  of  horizontal  canal.  Vertigo  less  from 
day  to  day.    Two  weeks  ago,  had  diplopia  for  three  days. 

Now  no  vertigo,  ny.  rotat.  r.  and  1.  Rode  home  (5  hours) 
on  train.  On  account  of  vertigo,  stood  the  ride  poorly. 
Hears  (exclusion  apparatus)  Con.v.  a.c;  middle  fork,  when 
vibrating  very  loud,  is  heard  a  few  seconds  by  r.  ear.  Ci  0, 
e*  -f- ;  110  fistula  symptom.    Cal.  react,  typical,  but  weak. 

Tr.  1.  =  after  ny.  horizontal  r.  4  movements  in  8". 

Tr.  r.  =  after  ny.  horizontal  1.  15  movements  in  14". 

Kathode  divided  —  anode  to  forehead,  ny.  rotat.  r.,  10 
M.A.     Slight  vertigo. 


148  DISEASES  OF  THE  LABYBIXTH 

Anode  divided  — .kathode  to  forehead,  ny.  rotat.  1.,  12 
M.A. 

R.  and  1.  tested  singly  give  typical  galvanib  reactions, 
4-5  M.A. 

Feb.  16,  1910:  Cal.  react,  plain.  Lond  words  perceived 
a.c.    No  fistula  symptom.    No  vertigo. 

40.  I.  H.  Age  17  years.  Peddler.  Admitted  Nov.  18,  1909. 

Anamnesis :  Discharge  I.e.  one  year  ago,  without  known 
cause.  Eight  days  ago,  perforation  behind  the  ear.  No 
headache  or  vertigo.    Slight  feeling  of  tightness  in  head. 

Status  praesens:  R.e. :  membrane  cloudy,  retracted. 
L.e. :  polyps,  fetid  discharge,  retro-auricular  fistula. 

Functional  test:  Con.v.  I14  m. ;  whisp.  25  cm.  (exclusion 
apparatus).  R.  — ,  Sch.  shortened,  Ci  0,  c*  -+-.  Spont.  ny. 
only  in  extreme  abduction.  Cal.  react,  weak  after  removal 
of  polyps,  before  which  it  could  not  be  elicited.  Fistula 
sympt.  -f-  for  a  few  times  only. 

Operation,  Nov.  19  (Bondy) :  Large  cholesteatoma  in 
smooth-walled  cavity  of  mastoid.  Sinus  lies  free  and  is 
thickened.  Cholesteatoma  lies  posterior  between  dura  and 
bone,  so  that  bone  is  removed  until  healthy  tissue  is  en- 
countered. Dura  of  posterior  fossa  also  exposed.  Hori- 
zontal canal  appears  indistinct.  At  its  level,  a  fine  fistula 
(?).  Irrigation  with  saline  at  room  temp,  produces  no  eye 
movement. 

Nov.  20:  Temp.  36.5,  37.2.  Ny.  rotat.  of  second  degree 
to  healthy  side.  Tested  with  exclusion  apparatus,  hears 
loud  con.v.  fairly  well  through  dressing. 

Nov.  21:  Temp.  37.3. 

Nov.  22 :  Afebrile  and  ny.  less.    Hearing  fair. 

Nov.  25 :  First  dressing.  Con.v.  perfectly  perceived.  Ir- 
rigation with  saline,  48°,  gives  decided  lessening  of 
spont.  ny. 

Nov.  26:  Transferred  to  O.P.  Dept. 

Jan.  17,  1910:  Wound  cavity  fully  covered  with  epi- 
dermis.   Con.v.  8  m.    Whisp.  ^,4  i^a.    With  exclusion  appa- 


CASE  UlSTOEIES  149 

ratus :  Con.v.  5  m.,  ^Y.  1.,  R.  — ,  Sch.  shortened.  Ci  +.  C*  -f, 
ai  -\-,  all  when  vibrating  very  little.  Fistula  sympt.  — . 
Cal.  react,  very  prompt,  with  ether  apparatus. 

Tr.  r.  =  after  ny.  horizontal  1.  15". 

Tr.  1.  =  after  ny.  horizontal  r.  25", 

Gal. :  Kathode  divided,  anode  to  forehead  =  ny.  rotat.  1., 
very  plain. 

Anode  divided,  kathode  to  head  =  ny.  rotat.  r.,  very  plain. 

41.  R.  B.  Age  24.  Male.  Admitted  Nov.  22,  1909. 

Anamnesis:  Occasional  suppuration  1.  since  his  twelfth 
year.  Then  a  dry  perforation  was  found  in  r.  drumhead. 
The  duration  of  the  suppuration  1.  averaged  8  months. 
Then  intervals  of  1  to  11/2  years.  But  even  during  the  pe- 
riods of  discharge  there  were  intervals  of  cessation,  at  times 
lasting  3-4  weeks.  Becavise  of  extensive  discharge,  he  was 
operated  (radical)  in  April,  1906.  Then  two  perforations 
of  the  1.  membrane  were  noted.  Operation  was  considered, 
but  local  treatment  gave  improvement  for  a  while.  Hear- 
ing fair.  No  headache  or  vertigo.  Sept.  15,  there  was  pain 
in  1.  parietal  region,  spreading  to  face  and  shoulder.  From 
Sept.  16  to  20,  very  intense  pains,  preventing  sleep,  great 
sensitiveness  to  pressure  about  the  ear.  Improved  by  hot 
applications.  Sept.  18,  as  pain  subsides,  vertigo  and  nau- 
sea.   Last  suppuration  began  July,  1909. 

Sept.  22.  Admitted  to  hospital. 

Status  praesens:  R.e. :  Healed  radical  operation.  L.e. : 
Drumhead  obscured  by  swelled  posterior  superior  meatal 
wall.    Canal  filled  with  pus.    Mastoid  not  sensitive. 

Functional  test:  Con.v. :  r.  6  m.,  1.  IV2  111.  Whisp.:  r.  a.c, 
1.  a.c.  (exclusion  apparatus  used).  W.  r.,  R.  both  sides  — , 
Sch.  shortened,  both  sides.  Ci:  w^eak  both  sides;  c^  r.  -f, 
1.  0.  Spont.  ny.  rotat.  r.  =  1.  in  abduction.  Reversed  fis- 
tula sympt.  1.    Cal.  tests  not  made.    Temp.  37.4. 

Operation,  Sept.  23  {Ernst  Urbantschitsch) :  T}T)ical 
radical.  Cholesteatoma  in  antrum.  Horizontal  canal  in- 
tact.   Below  the  oval  window,  a  small  area  discolored  and 


150  DISEASES  OF  THE  LABYRINTH 

covered  with  small  granulations.  Probe  passes  here  with- 
out resistance.  Pressure  produces  movement  of  eyeballs 
to  extreme  1.  (diseased  side). 

Sept.  23:  Comfortable.     No  ny.     Facial  intact. 

Sept.  24:  Comfortable.  No  ny.  No  vertigo.  Hearing 
through  dressing  good  (exclusion  apparatus  used).  Temp. 
36.5,  37.4. 

Sept.  25:  Feels  well.  Spont.  ny.  rotat.  r.  =  1.  is  slight. 
No  vertigo ;  temp.  36.7,  37.2. 

Sept.  26 :  No  fever  or  vertigo.  Facial  intact,  but  patient 
complains  of  excessive  flow  of  tears,  1.  Temp,  normal.  Eve- 
ning comfortable.  Slight  weakness  of  1.  eyelid,  but  eye  can 
be  closed  perfectly.    L.  angle  of  mouth  shows  slight  rigidity. 

Sept.  27 :  Comfortable.  No  vertigo  or  nausea.  No  head- 
ache. Facial  paresis  more  distinct,  but  eye  can  be  closed. 
Dressing.  No  pus.  Below  and  in  front  of  the  ampulla  a 
second  fistula  is  seen,  into  which  the  probe  can  be  passed. 
Patient  being  unconscious  during  dressing,  no  functional 
test.  14  hour  later,  hearing  remains  unchanged  (through 
dressings) ;  some  words  correctly  heard. 

Sept.  28:  Dressing.  Cal.  react,  present.  AVords  spoken 
softly,  heard.    Middle  fork  -{-.    Temp,  normal. 

Sept.  29 :  Some  vertigo,  otherwise  condition  is  normal. 

Sept.  30:  Vertigo  somewhat  greater,  otherwise  no 
change.  Facial  unchanged.  Dressing.  Fistula  no  longer 
plainly  visible. 

Unchanged  condition  until  patient  is  transferred  to  O.P. 
Dept.,  Oct.  6. 

42.  St.  H.  Age  20.  Female. 

Anamnesis :  Measles  as  child.  Patient  does  not  recall 
that  she  had  ear  trouble  at  that  time.  She  only  remembers 
that  she  had  discharge  two  years  ago,  and  because  of  pain 
and  tenderness  on  pressure  she  had  local  treatment.  Dur- 
ing past  week,  vertigo,  particularly  on  moving  head.  No 
headache  or  fever.    More  vertigo  on  lying  on  1.  side. 

Status  praesens:  E.e. :  Chronic  suppuration. 


CASE  HISTORIES  151 

Functional  test:  Hearing:  Con.v.  1-2  m.  (exclusion  ap- 
paratus used) ;  W.  r.,  R.  — ,  Ci  -}-,  C*  +.  No  spont.  ny. 
(perhaps  slight  rotat.  ny.  on  looking  to  1.)-  Fistula  sympt. 
typical,  distinct.    Aspiration  ny.  weaker  than  compression 

ny- 

The  specialist  who  treated  patient  in  the  country  obtained 
marked  cal.  react.,  due  to  pressure,  no  doubt.  No  marked 
equilibrium  disturbances.  On  walking  with  eyes  closed,  go- 
ing backward,  slight  deviation  and  falling  to  r.  Turns  about 
body  axis  r.  and  1.  without  vertigo. 

Operation,  Dec.  24,  1909  (Ruttin) :  Mastoid  very  much 
sclerosed,  antrum  filled  with  granulations,  undermining  the 
sinus  behind.  Dura  not  exposed.  In  the  horizontal  canal, 
a  round  fistula,  the  size  of  a  pinhead.  Pressure  here  causes 
a  slow  movement  of  the  eyes  to  r.  Typical  radical  opera- 
tion. I  saw  patient  one  year  later.  Complete  epidermiza- 
tion.  No  spont.  ny.  Hearing  distance  more  than  one 
meter.* 

43.  K.  K.  Age  46.  Female.  Admitted  Jan.  5,  1910. 

Anamne.sis:  Discharge  1.  30  years.  18  yrs.  ago,  polyps 
removed.  During  past  few  weeks,  vertigo  and  headache  in 
the  1.  ear  and  vertex. 

Status  praesens:  R.e. :  normal.  L.e. :  drumhead  present. 
Polyp  from  attic.  Con.v.  1  m.,  whisp.  a.c.  (with  exclusion 
apparatus).  W.  1.,  E.  — ,  Sch.  lengthened,  Ci  0,  c^  +.  No 
vertigo  at  present.  No  spont.  ny.;  fistula  sympt.  +,  with 
vertigo.    Cal.  react,  typical. 

Operation,  Jan.  7  (Rnttin) :  Antrum  small,  like  a  cleft. 
Bone  sclerotic.  Typical  radical  operation.  Horizontal 
canal  deformed ;  in  its  place,  three  exostoses.  Two  fistulae, 
one  small  one,  high  up  between  two  exostoses,  the  second 
in  front  of  the  first  exostosis,  above  the  horizontal  portion 
of  the  facial  canal,  in  the  typical  position. 

■  *  I  saw  patient  in  Jan.,  1912.  again.  She  is  completely  healed.  The  opera- 
tive wound  is  covered  with  epidermis.  No  fistula  symptom.  Hears  2  m.  +. 
No  symptoms  whatever. 


152  DISEASES  OF  THE  LABYRINTH 

Jan.  8:  Xy.  rotat.  r.  slight.    Xo  vertigo.    Emesis. 

Jan.  9:  As  above. 

Jan.  10:  Xo  ny.  or  vertigo.    Xo  emesis,  some  headache. 

Jan.  J4:  Dressing.  Cal.  react,  positive,  but  slow.  Deaf 
(tested  with  exclusion  apparatus).    Xo  spont.  ny. 

Jan.  17 :  Cal.  react,  plain.    Deaf.    Xo  fistula  reaction. 

Jan.  20:  Until  now,  afebrile.    To-day,  38.1. 

Jan.  21:  Afebrile.  Jan.  22,  39.1,  38.5;  Jan.  23,  39.8,  38.4; 
Jan.  24,  37.6,  37.7;  Jan.  25,  37.3,  38.6;  Jan.  26,  38.0,  39.6; 
Jan.  27,  37.5,  39:3;  Jan.  28,  38.5,  40.0,  38.1. 

Internal  examination  (Dr.  S.  Bondy) :  *' Catarrh"  in  both 
upper  lobes.  Mitral  insufficiency,  arteriosclerosis.  Fever 
cannot  be  accounted  for  by  internist. 

Second  operation  (Ruttin) :  Exposure  of  sinus  and  the 
dura  of  the  middle  and  posterior  fossae,  both  normal. 

Patient  was  removed  from  the  hospital  by  relatives.  Died 
the  next  day.    Cause  of  death  unexplained. 

44.  M.  S.  Age  33.  Male.  Admitted  Jan.  12,  1910. 

Anamnesis:  Pains  for  past  six  months.  Discharge  for 
two  months.  Emesis  once.  Pains  continuous;  frequent 
vertigo. 

Status  praesens:  E.e. :  normal.  L.e. :  polyps  in  canal, 
fetid  pus. 

Functional  test:  AVith  exclusion  apparatus  to  r.e. :  deaf. 
"W.  r.,  R.  — ,  Ci  0,  c"*  0.  Spont.  ny.  rotat.  r.  =  ny.  rotat.  1. 
With  head  inclined  to  1.,  nj.  rotat.  1.,  and  with  head  inclined 
to  r.,  ny.  rotat.  r.  Cal.  react.  =  0.  Fistula  sympt.  +,  and 
very  active,  provoked  by  slightest  pressure  on  the  tragus. 

Tr.  1.   =  after  ny.  horizontal  r.  15". 

Tr.  r.  =  0. 

No  fever.    Advanced  phthisis. 

Operation,  Jan.  14  (Prof.  Urbantschitsch) :  The  opened 
mastoid  shows  extensive  destruction.  A  sequestrum  as  large 
as  a  bean,  made  up  of  cells  from  about  the  antrum.  The  hori- 
zontal semicircular  canal  perforated  like  a  sieve.  Dura  of 
the  middle  and  posterior  fossae  lies  exposed  and  is  cov- 


CASE  HISTORIES  153 

ered  with  spong}'  granulations.  Facial  nerve  lies  exposed. 
Twitching  of  face  when  tympanic  cavitj-  is  scraped. 

Jan.  15.  Temp.  37.7.    Facial  paresis. 

Jan.  20:  Dressing.  AYound  granulating.  Deaf  1.  (tested 
with  exclusion  apparatus).  Spont.  rotat.  ny.  r.  No  cal.  re- 
act. Fistula  sympt.  cannot  be  elicited.  Jan.  21,  temp.  37.3 ; 
Jan.  22,  37.7. 

Jan.  24 :  Totally  deaf  1.  *  Irrigation  produces  slight  ca- 
loric reaction ;  i.e.  the  suspended  reaction  has  been  restored. 

Tr.  r.  =  no  trace  of  ny. 

Tr.  1.  =  after  ny.  r.  21  movements  in  241/2". 

Jan.  26:  Total  deafness  1.  Cal.  react,  plain,  but  slight, 
with  hot  and  cold  irrigation. 

Jan.  30,  temp.  37.4;  Feb.  2,  38.1. 

Feb.  3 :   Transferred  to  O.P.  Dept. 

Patient  later  treated  for  tuberculosis. 

45.  K.  B.  Male.  Admitted  Jan.  17,  1910. 

Anamnesis :  L.e.  diseased  for  20  yrs.  Does  not  know  that 
ear  is  discharging,  but  is  conscious  of  pain.  8  days  ago 
polyps  were  removed.  No  headache,  no  vertigo,  no  emesis. 
Temp,  normal. 

Status  praesens:  R.e. :  normal.  L.e.:  membrane  totally 
destroyed.  Polyps.  Con.v.  21/0  m.  "Whisp.v.  10  cm.  W.  in 
head.  R.  — .  Sch.  shortened.  Cj  0,  c*  shortened;  spont. 
ny.  rotat.  r.  =  ny.  rotat.  1.  No  fistula  symptom.  Typical 
cal.  ny. 

Operation,  Jan.  19  (Dr.  Rauch) :  Typical  radical.  Choles- 
teatoma in  antrum.  Fistula  in  horizontal  canal,  about  2 
nam.  long,  discolored.    Temp.  37.7. 

elan.  20:  Comfortable.  Temp.  36.8,  37.7;  Jan.  21,  37.4; 
Jan.  22,  36.9;  Jan.  23,  37.3;  Jan.  24,  37.1;  first  change  of 
dressing;  Jan.  25,  38.7;  Jan.  26,  normal. 

Jan.  23:  A.M.,  patient  complains  of  vertigo;  on  sitting 
up,  has  severe  ny.  rotat.,  at  times  r.,  again  1.  There  are 
severe  attacks  of  ny.  When  head  is  bent  backward,  ny.  is 
upward. 


154  DISEASES  OF  THE  LABYFINTH 

Jan.  24 :  Xy.  rotat.  r'.,  large,  rolling,  of  third  degree,  with 
severe  vertigo  and  emesis.  Hears  through  dressing.  With 
dressing  removed,  he  hears  eon  v.  v.  well  (exclusion  appa- 
ratus). W.  in  diseased  ear.  Middle  fork  scarcely  heard  at 
ear,  even  when  vibrating  after  heavy  blow.  A^  only  heard 
for  short  time.  Cal.  react,  (hot  saline)  causes  cessation  of 
the  spont.  ny.  with  the  appearance  of  ny.  to  diseased  side. 
Fistula  sympt.  not  to  be  elicited  by  pressure  on  the  horizon- 
tal semicircular  canal. 

Jan.  25 :  Large,  rolling  ny.  rotat.  r. ;  but  only  of  second 
degree.  Vertigo  less,  particularly  on  sitting  up.  Dressing. 
Totally  deaf  1.  Cal.  test  (hot  saline)  produces  a  distinct 
ny.  to  the  diseased  side.  The  ny.  to  healthy  side  ceases.  No 
headache.    Temp.  38.7. 

Jan.  26 :  Temp,  normal.  No  headache.  Hears  (with  ex- 
clusion apparatus  r.)  con.v.  1.,  but  does  not  make  out  the 
words.  With  conversation  tube,  hears  single  words  when 
spoken  fairly  loud ;  when  spoken  near  the  tube,  he  does  not 
hear.  A^  heard  for  a  moment.  Cal.  react. — ;  cold  gives  ny. 
rotat.  r.  of  second  degree,  while  spont.  ny.  rotat.  r.  is  m- 
ereased  on  looking  to  r. 

Jan.  27 :  Less  spont.  ny.  r.  No  vertigo,  except  on  sitting 
up.  No  headache  or  fever.  L.e.  totally  deaf.  Cal.  react, 
distinct. 

Jan.  28 :  Less  spont.  ny.  rotat.  r. 

Jan.  30:  Cal.  react,  distinct. 

Feb.  3:  Dressing.  Total  deafness  1.,  perhaps  a  trace  of 
hearing  with  the  intermediate  tuning  fork.  Cal.  react, 
prompt. 

Feb.  9.  L.e.  totally  deaf.    Slight  spont.  ny.  rotat.  1. 

Tr.  r.  =  ny.  horizontal  1.  4  movements. 

Tr.  1.   =  ny.  horizontal  r.  15". 

46.  A.  H.  A^e  28.  Male.  Admitted  Feb.  3, 1910. 

Anamnesis:  Patient  first  consulted  me  privately  three 
years  ago  for  deafness.  Does  not  recall  that  ear  ever  dis- 
charged.   R.e.  totally  deaf;  I.e.  perceived  loud  voice  a.c.    At 


CASE  HISTOBIES  155 

tliat  time  I  stretclied  the  adhesions  of  the  liammer  handle 
by  means  of  the  hook,  and  the  hearing  was  decidedly  better 
for  a  while.  This  procedure  was  repeated  several  times 
with  good  results  during  the  year,  and  he  could  attend  to 
his  duties.  Then  I  lost  sight  of  him  for  two  years.  Early 
in  1910  he  returned,  complaining  of  attacks  of  severe  head- 
ache and  vertigo.  No  spont.  ny.  No  fistula  sympt.  Hear- 
ing as  before.  Neurological  exam,  showed  possibility  of 
tabes  (had  lues).  In  the  region  of  the  antrum,  small  scales. 
I  prescribed  hot  compresses,  and  asked  him  to  return. 
Examination  after  two  weeks:  A  drop  of  pus  aspi- 
rated from  the  region  of  the  antrum.  Fistula  symp- 
tom very  plain,  and  on  compression  slight  ny.  to 
the  diseased  side ;  on  aspiration,  to  the  healthy  side.  Aspi- 
ration is  more  effective  than  compression. 

Jan.  26 :  Vertigo  and  headache  less.  No  spont.  ny.  Fis- 
tula sympt.  not  demonstrable.  Cal.  react,  (cold  air) 
prompt.    No  vertigo,  headache  or  emesis. 

Status  praesens:  Feb.  3,  R.e. :  con.v.  deaf,  also  for  tun- 
ing forks.  L.e. :  con.v.  5-6  m. ;  whisp.  a.c. ;  W.  in  head,  R.  — , 
Sch.  shortened;  Ci  and  c'' +.  No  spont.  ny.  Fistula  sympt. 
0,  but  was  present  two  weeks  ago.    Temp.  37.0  to  37.4. 

Tr.  1.  =  after  ny.  horizontal  r.  22". 

Tr.  r.  =  after  ny.  horizontal  1.  20". 

Cal.  react.  +. 

Operation,  Feb.  7  (Ruttin) :  Mastoid  sclerotic.  Radical 
operation  with  preservation  of  the  ossicles,  according  to 
Bondy's  method.  The  ossicles  are  distinctly  seen  in  the 
antrum  after  removal  of  the  bridge.  A  fistula  cannot  be 
found  in  the  horizontal  canal,  though  this  cannot  be  all  in- 
spected. A  few  granulations  in  the  antrum.  Dura  of  the 
posterior  fossa  laid  bare  to  ilie  extent  of  a  one  heller  piece. 

Feb.  9 :  Comfortable,  some  ny.  rotat.  r.,  no  vertigo. 

Feb.  10 :  Comfortable,  some  ny.  rotat.  r.  Less  than  yes- 
terday.   No  vertigo. 

Feb.  12:  Dressing.  Wound  clean.  Hears  con.v.  7  m.; 
savs  he  hears  better  than  before  the  operation.    Dismissed 


156  DISEASES  OF  THE  LABYRIMII 

for  ambulatory  treatment.    Temp,  regularly  between  37.0 
and  37.5.* 

47.  L.  F.  Age  23.  Male.  Admitted  Feb.  11,  1910. 

Anamnesis :  Since  Dee.  31,  1909,  when  he  received  a  blow 
on  the  1.  ear  while  bathing,  pain  and  discharge.  Was  then 
at  the  clinic  in  Lemberg.  Vertigo  during  the  past  few  days, 
with  increased  pain. 

Status  praesens:  E.e. :  normal.  L.e. :  upper,  posterior 
and  anterior  walls  of  external  canal  swelled,  so  that  canal 
is  greatly  narrowed.  At  the  bottom  of  the  canal,  pulsating 
secretion.  Membrane  not  visible.  Mastoid  somewhat  sensi- 
tive to  tapping. 

Temp,  normal. 

Functional  test:  E.e.:  normal.  L.e. :  con.v.  1  m.  Whisp. 
a.c.  (with  exclusion  apparatus).  W.  1.,  E.  — ,  Sch.  length- 
ened; Ci  +)  c^  +•  Tinnitus  only  on  1.  side.  Vertigo  pres- 
ent. Spont.  ny.  rotat.  r.  =  ny.  rotat.  1.  Tr.  1.  =  after  ny. 
lioriz.  r.  15".  Tr.  r.  =  after  ny.  horiz.  1.  32".  Cal.  react.  0. 
Fistula  sympt.  +,  on  compression,  ny.  horiz.  and  rotat.  r. ; 
on  aspiration,  most  severe  ny.  rotat.  1.  and  much  stronger 
than  on  compression.    Temp.,  Feb.  14,  37.4. 

Operation,  Feb.  14  (Ernst  Urbants  chit  sch) :  Incision 
through  the  infiltrated  soft  parts.  Mastoid  pneumatic,  con- 
taining thick,  pulsating  non-smelling  pus.  Many  granula- 
tions. Posterior  meatal  wall  softened.  Eadical  operation. 
In  the  horizontal  canal,  a  fistula  larger  than  a  millet  seed. 
Sinus  lies  exposed.    Plastic,  etc. 

Feb.  15:  Comfortable.    Temp,  normal. 

Feb.  17:  As  above. 

Feb.  18 :  Slight  spont.  ny.  rotat.  r.  Comfortable ;  gets  up. 

Feb.  19:  Dressing.     Temp.  37.6. 

Meh.  21:  Dismissed  to  the  O.P.  Dept. 

After  examination,  May  3 :  No  spont.  ny.    L.e.  deaf  for 

•  Note  during  reading  of  proof:  The  patient  came  for  examination  in  Jan., 
1912.  The  operative  area  entirely  covered  and  dry.  Hearing  for  con.  v.  7  m. 
No  fistula  sympt.     No  symptoms. 


CASE  HISTOFIES  157 

speech  and  timing  forlvs.  ^Y.  r.  Tr.  r.  =  after  ny.  horiz. 
].  20".  Tr.  1.  =  after  ny.  r.  20".  Cal.  react,  not'present 
(perhaps  a  trace).    Fistula  sympt.  negative. 

48.  J.  M.  Locksmith.  Admitted  Mch.  30, 1910. 

Anamnesis:  Two  yrs.  ago,  sudden  pain  in  h  ear,  fol- 
lowed at  once  by  discharge,  lasting  one  week.  No  symp- 
toms for  one  year.  Last  year  a  repetition  of  the  same  proc- 
ess occurred,  lasting  two  weeks.  Five  weeks  ago,  sudden 
tinnitus,  headache  and  discharge.  During  past  two  weeks, 
attacks  of  vertigo.    To-day,  emesis. 

Status  praesens:  K.e. :  Membrane  cloudy,  retracted. 
L.e. :  Membrane  entirely  destroyed.  Granulations.  Ex- 
ternal canal  narrowed ;  pulsating  pus. 

Functional  test:  Con.v.  %  m.,  whisp.  a.c.  Tinnitus  now 
and  then.  W.  1.,  R.  — ,  Sch.  lateralized  to  the  healthy 
side  (?).  Ci  0,  c^  -f--  Vertigo  present.  Spont.  ny.  rotat. 
r.  and  1.  Cal.  react.  0.  Tr.  r.  =  no  after  ny.  Tr.  1.  =  horiz. 
ny.  r.  15".  Fistula  sympt.  +;  on  compression,  ny.  r. ;  on 
aspiration,  stronger  ny.  1.    No  fever. 

Operation  {Ernst  Urhantschitsch) :  Mastoid  pneumatic, 
filled  with  pus  and  granulations.  Radical  operation.  In 
horizontal  canal,  a  fistula,  3  mm.  by  1  mm.  Bone  diseased 
up  to  the  sinus.  Large  cells  filled  with  pus  toward  the  bulb 
of  the  jugular. 

'  Mch.  31 :  Comfortable,  no  vertigo,  no  nausea,  no  vomit- 
ing.   Spont.  ny.  not  changed.    No  fever. 

Apr.  1 :  The  same.  Apr.  2 :  No  vertigo,  no  nausea ;  some 
retching.    Spont.  ny.  rotat.  r.  on  looking  to  r.  and  forward. 

Apr.  3 :  A.M.,  had  some  vertigo  and  feeling  of  weakness. 
Some  tinnitus.  A  little  headache.  Apr.  5:  No  vertigo; 
slight  rotat.  ny.  r.  Dressing.  Wound  healing.  Apr.  7: 
Dressing.  Condition  excellent ;  slight  ny.  rotat.  r.  on  look- 
ing to  r.    Transferred  to  O.P.  Dept. 

49.  K.  M.  Age  37.  Ironworker.  Admitted  May  19,  1909. 
Anamnesis:    Both  ears  have  discharged  for  18  years. 


158  DISEASES  OF  THE  LABYRINTH 

Pain  in  r.e.  for  past  14  days.     Paracentesis.     Pains  con- 
tinue.   No  vertigo  or  emesis. 

Status  praesens:  R.e.:  Marked  swelling  and  redness  of 
drumhead.  Much  discharge.  Perforation  with  pulsating 
pus  in  posterior-superior  quadrant.  L.e. :  Perforation, 
polyps,  slight  discharge. 

Functional  test:  Con.v.  r.  1  m.,  1.  7  m.  Whisp.  r.  a.c, 
1.  3  m.  W.  indefinite.  R.  r.  — ,  1.  +.  Bone  conduction,  both 
sides  shortened.  Ci  both  sides  -{-,  c^  both  sides  +.  No  ver- 
tigo or  spont.  ny.  No  fistula  symptom.  Cal.  react,  both 
sides  prompt. 

May  29:  Patient  treated  about  eight  days  by  means  of 
attic  irrigations.  Condition  remains  unchanged,  pus  flow- 
ing from  above  and  backward.  Immediately  after  to-day's 
irrigation  patient  complained  of  vertigo. 
•  May  30:  Vertigo  almost  continuous  since  yesterday, 
especially  on  bending,  coughing  and  moving  head  to  1. 
Head  movements  to  r.  cause  no  vertigo.  Fistula  symp- 
tom +)  compression  causing  large,  slow,  rotatory  motion  to 
the  diseased  side,  followed  by  a  small  rotat.  ny.  to  the 
healthy  side.  Aspiration  causes  a  quick  rotat.  ny.  to  the 
diseased  side.  The  same  occurs  on  compression  and  re- 
lease of  the  tragus,  with  severe  vertigo.  Spont.  ny.  rotat.  1., 
loud  con.v.  a.c.  W.  1.,  R.  — .  Sch.  lengthened.  Ci  0.  c^  -f. 
Cal.  react.  -{-,  typical. 

Operation,  June  1  {Bondy) :  Sclerosed  mastoid.  Choles- 
teatoma in  antrum.  No  fistula  in  horizontal  canal.  Pres- 
sure in  region  of  oval  window  causes  slow  eye  movement  to 
the  diseased  side. 

After  the  operation:  Spont.  rotat.  ny.  1.  June  1,  A.M., 
some  vertigo,  but  on  quickly  moving  the  head  and  on  sitting 
up,  no  vertigo,  though  he  moves  without  hesitation. 

June  2:  Evening,  feels  comfortable.  Spont.  ny.  rotat. 
r.  =  l. 

June  4 :  No  vertigo  or  ny. 

June  5 :  Slight  rotat.  ny.  1.  on  looking  to  1.    Vertigo. 


CASE  HISTORIES  159 

June  6:  Headache.  Dressing.  Hears  voice,  but  can- 
not make  out  words.    Cal.  react,  distinct. 

June  7 :  Tr.  r.  =  after  ny.  horiz.  1.,  30  movements  in  20". 
Tr.  1.  ==  0,  possibly  some  ny.  dowTiward. 

50.  G.  F.  Age  35.  Woodchopper.  Admitted  May  21, 1910. 

Anamnesis:  Twelve  weeks  ago  patient  noticed  discharge 
1.  without  previous  pain.  No  previous  ear  trouble.  Slight 
vertigo.    No  emesis. 

Status  praesens:  E.e. :  Normal.  L.e. :  Central  perfora- 
tion. Abundant  discharge.  Posterior  superior  wall  of 
canal  bulging. 

Functional  test:  Con.v.  2  m.  Whisp.  5  cm.,  tinnitus.  W. 
in  head.  R.  — .  Sch.  shortened.  Ci  0,  c^  -f .  Vertigo  now' 
and  then.  Spont.  rotat.  ny.  r.  =  1.  Fistula  sympt.  -f.  On 
compression,  slow  movement  of  both  eyes  to  r.,  and  imme- 
diately thereafter,  ny.  1.  Aspiration,  only  slow  movement 
to  1.    Cal.  react,  weak.    No  fever  (ten  days). 

Operation,  May  31  (Prof.  Urbantschitsch) :  Mastoid 
sclerotic.  Antrum  filled  with  granulations.  No  fistula. 
Pressure  on  horizontal  canal  or  on  the  inner  wall  does  not 
produce  eye  movements.  Extra-dural  abscess  of  posterior 
fossa.  P.M.,  slight  rotat.  ny.  to  healthy  side.  Slight 
vertigo. 

June  1 :  Ny.  decidedly  increased  and  of  third  degree. 
Tested  with  exclusion  apparatus:  Con.v.  with  mistakes. 
Temp.  37.2. 

June  2:  Ny.  and  vertigo  increased.  Emesis.  Dressing 
changed.  Loud  voice  heard  w4th  mistakes.  Hot  irriga- 
tion (48°)  gives  distinct  ny.    Temp.  37.1. 

June  3:  Condition  the  same.  Dressing.  Emesis  less. 
Ny.  on  looking  to  the  diseased  side  not  visible.  Temp.  36.2, 
37.5. 

June  6:  No  vertigo.  Ny.  rotat.  r.  only  on  looking  to  r. 
Tested  w4th  exclusion  apparatus:  Con.v.  with  mistakes. 
Cal.  react.,  a  trace.    Temp,  normal. 

June  7:  Temp,  normal. 


160  DISEASES  OF  TEE  LABYBIKTE 

June  8 :  Cal.  react.  0.  L.e.  entirely  deaf.  No  fever.  Tr. 
r.  =  after-nv.  lioriz.  1.  10"  (12  movements).  Tr.  1.  =  ny. 
boriz.  r.  19"  (48  movements),  but  witbout  vertigo. 

June  18 :  Cal.  react,  prompt ;  no  spont.  ny.  Tested  with 
exclusion  apparatus:  Loud  words  beard  a.c.  Fistula 
sympt.  — .  Tr.  r.  =  after-ny.  boriz.  1.  8  movements  in  11". 
Tr.  1.  =  after-m'-.  boriz.  r.  45  movements  in  20". 

51.  O.  M.  Age  22.  Milliner.  Admitted  Sept.  15,  1907. 

Anamnesis:  As  cbild,  patient  bad  severe  beadacbe  on  r. 
side.  Tbree  years  ago,  erysipelas,  beginning  in  r.  eye,  and 
rbeumatism  in  tbe  bands  and  feet.  At  age  2  bad  suppura- 
tion r.  ear.  Drafts  bave  always  caused  pain  in  r.  ear  and 
r.  parietal  region.  Hearing  always  poor  on  r.  side,  and  bas 
always  bad  attacks  of  vertigo,  wbicb  were  never  as  severe 
as  of  late.  Has  always  bad  pains  in  r.  mastoid  and  parietal 
region.  L.e.  always  bealtby.  Tbree  weeks  ago,  tbe  dis- 
ebarge  became  very  marked;  sbe  bad  vertigo  and  more  se- 
vere pains  in  ber  bead  and  mastoid,  tbe  latter  sensitive  to 
pressure.  Tbis  condition  improved  in  one  day.  Two  weeks 
ago  sbe  suddenly  collapsed  and  became  unconscious.  On 
coming  to,  one-quarter  hour  later,  sbe  bad  severe  vertigo, 
witb  movement  of  objects  about  ber ;  emesis.  Had  also  very 
severe  beadacbe  (r.),  particularly  in  tbe  region  of  tbe  fore- 
head. Mastoid  very  sensitive  to  pressure.  Unable  to  stand 
up  since  tbis^  attack,  and  cannot  raise  ber  bead.  On  setting 
ber  up,  sbe  complains  of  the  vertigo,  and  tbe  ny.  becomes 
more  severe.    Frequent  emesis. 

Status  praesens:  L.e.:  Filled  with  bad-smelling  pus,  and 
inflamed  tissue  (granulations).  E.e. :  Very  fetid  pus  in  the 
canal.  Inner  wall  of  tjTnpanic  cavity  covered  witb  granu- 
lations. Pus  comes  especially  from  the  region  of  the  an- 
trum. Mastoid  very  sensitive  to  pressure  (this  may  be  due 
to  hysteria). 

Functional  test:  The  labyrinth  does  not  react  to  the  cal. 
test.  W.  to  1.  E.  — .  Tuning  forks  not  heard  through  the 
air.    Severe  rotat.  ny.  to  bealtby  side. 


CASE  HISTORIES  161 

Labyrinth  operation,  Oct.  23,  4  P.  M.  {Bdrdny) :  Typical 
radical  operation  under  local  anaesthesia.  Bone  very  hard, 
sclerosed.  In  the  antrum,  a  very  fetid  cholesteatoma,  the 
size  of  a  hazelnut,  reaching  into  the  mastoid.  Exposure  of 
the  sinus,  which  is  w^l  forward,  a  distance  of  1  cm.  Dura 
of  the  middle  fossa  laid  bare  the  size  of  a  five  Kronen  piece. 
Procedure  with  the  typical  labyrinth  operation,  by  remov- 
ing larger  fragments  of  bone.  The  upper  angle  of  the 
pyramid  is  removed.  The  vestibule  is  opened  from  behind, 
when  the  upper  portion  of  the  facial  bend  of  the  facial  canal 
is  broken,  so  that  the  facial  nerve  lies  free  in  the  tympanic 
cavity,  but  is  not  injured.  Cochlea  opened  from  the 
promontory,  when  a  large  amount  of  fluid  escapes.  Plastic 
after  Panse.  Vestibule  drained  from  behind,  cochlea  from 
in  front.    Until  Oct.  28,  temp,  is  about  37.8. 

Oct.  28 :  Change  of  dressing.  Normal  temp,  from  now  on. 

Oct.  30:  Dressing. 

Nov.  7 :  Regular  dressing  every  other  day.  Tlie  dura  lies 
rather  low.    Facial  paresis.    Comfortable. 

Nov., 8:  Dressing.  Dura  of  the  posterior  and  middle 
fossae  adherent. 

Nov.  12:  Dressing.  Pulse  118.  Headache.  Ny.  to  1.  on 
looking  to  1.  in  slight  degi'ee. 

Nov.  12-19 :   Dressing  every  other  day. 

Nov.  19 :  Patient  discharged  well.  Eotat.  ny.  to  each  side 
marked.  Wound  cavity  size  of  hazelnut.  The  prolapsed 
dura  adherent  to  the  facial  spur.  Slight  secretion.  Or- 
dered to  come  for  daily  dressing. 

52.  J.  F.  Age  28.  Female.  Admitted  Nov.  6,  1907. 

Anamnesis:  Patient  has  had  discharge  from  1.  ear  two 
years.  Stopped  for  a  while.  Following  a  confinement  ten 
months  ago,  it  returned.  Two  days  ago  she  was  brought 
to  the  surgical  clinic  with  a  high  fever.  Transferred  to  this 
clinic. 

Status  praesens:  Internal  examination  negative.  R.e.: 
A  calcification  in  anterior  portion  of  drum ;  above,  a  perfo- 


162  DISEASES  OF  THE  LABYRIMH 

ration  opposite  the  antrum  and  covered  with  a  granulation. 
From  behind  this,  thin  pus  flows  out;  mastoid  is  sensitive 
to  pressure.  L.e. :  A  dry  perforation,  the  size  of  a  pinhead. 
Patellar  reflex  present,  slightly  increased.  Dermography 
present.  Kernig  not  present.  Bahinski  negative.  Neck 
rigid.  Frontal  headache.  Slight  anisocoria.  Pulse  72. 
No  emesis.    Temp.  39.0. 

Functional  test:  L.e.:  Normal.  E.e. :  Deaf  for  voice  and 
tuning  forks.  W.  1.,  R.  — ,  Ci  and  c^  heard  when  struck  with 
metal.  Fistula  symptom  — .  Cal.  react.  — .  Large  spont. 
rotat.  ny.  1.    Temp.,  Nov.  7,  39.1. 

Operation,  Nov.  7  (Prof.  Urh  ants  chit  scli) :  Eadical 
operation.  Dura  and  sinus  laid  bare.  They  are  unchanged. 
After  the  sinus  has  been  widely  exposed,  the  tympanic  cav- 
ity is  cleared  of  granulations,  likewise  the  antrum,  tlam- 
mer  and  anvil  are  not  to  be  found.  The  horizontal  semicir- 
cular canal  is  now  opened,  and  also,  after  crowding  the 
sinus  and  the  dura  back,  the  posterior  vertical  semicircular 
canal  is  opened  from  behind.  The  promontory  was  then 
opened.  No  cerebrospinal  fluid.  As  the  promontory  was 
being  chiseled,  a  fragment  of  the  facial  ridge  became  de- 
tached. Through  this  ran  the  facial  nerve.  This  piece  was 
cut  down  to  a  minimum  by  the  bone-cutting  forceps.  No 
facial  twitching.  Plastic;  at  the  close  of  the  operation  a 
lutnbar  punctiire  was  made,  giving  diffuse,  cloudy  cerebro- 
spinal fluid.  (Bacteria:  Gramnegative  cocci.)  Saline  in- 
fusion. 

Nov.  8 :  Night  tolerably  comfortable.  Some  headache  on 
moving  and  on  jarring  the  bed.  Severe  pains  in  the  head. 
Facial  paresis.    Ny.  rotat.  1.    Temp.  37.5. 

Nov.  9 :  General  condition  not  bad.  Photophobia.  Some 
headache.    Temp.  37.8. 

Nov.  10:  Temp.  37.6.  Nov.  11:  37.6.  From  Nov.  12: 
normal. 

Nov.  13:  Patient  improves  remarkably,  with  no  temp. 
Headaches  less.    Sits  up.    Appetite  good. 

Nov.  14 :  First  change  of  dressing.    Wound  bleeds.    The 


CASE  HISTORIES  163 

sequestrum  on  the  facial  nerve  is  still  loose  and  is  left. 
Slight  discharge. 

Nov.  16:  Patient  feels  well.  Dressing.  The  sequestrum 
is  already  attached  by  granulations,  only  slightly  movable. 

Nov.  18:  Dressing.  The  sequestrum  is  surrounded  by 
granulations  and  is  not  to  be  seen. 

Nov.  28 :  Wound  normal.    Transferred  to  O.P.  Dept. 

53.  J.  S.    Agent.    Admitted  Feb:  2,  1908.  P.  M. 

Anamnesis :  Chr.  suppuration  1.  with  occasional  exacer- 
bations. Four  days  ago,  very  severe  headache,  slight 
stupor.  Temp.  38.6.  Hearing,  r.,  normal;  1.,  noticeably 
diminished. 

Status  praesens:  L.  perforation,  superior  posterior 
quadrant.  Fetid  secretion.  Mastoid  and  head  not  sensi- 
tive. No  stiffness  of  neck  or  sensitiveness  of  spinal  column. 
Pupils  different  in  size;  they  react  slowly.  Convergence 
weak.  Slight  ptosis  1.,  facial  paresis,  1.  Motor  strength  on 
both  sides  good.  Perhaps  some  hyperaesthesia.  Patellar 
reflex  almost  absent.  Babinski  positive.  Speech  slow. 
Slow  cerebration.  Complains  of  most  severe  pains  in  en- 
tire head.  On  standing  up,  an  attack  of  ny.  to  1.  rotat., 
very  large  (after  5  hours,  a  trace  of  rotat.  ny.  r.).  Hear- 
ing greatly  diminished  on  both  sides.  No  fistula  symptom. 
Cal.  react,  two  days  ago  positive.  Slight  ataxia.  Moist 
rales  over  the  lungs.  Pulse  soft,  90.  P.M.,  2i/2  hours  later : 
Unconscious.  Rt.  eye  deviates  outward.  Large  ny.  to  1. 
rotat.  Does  not  arouse,  picking  at  the  bedclothes.  Kernig 
probably  present.    Ophthalmoscopic  exam,  impossible. 

Radical  operation,  Feb.  2  {Bdrdny) :  Mastoid  filled  with 
pus.  Much  pus  in  the  antrum.  Sinus  is  exposed,  when  the 
emissary  vein  (II/2  cm.  long)  bleeds.  Stops  on  packing. 
Sinus  very  thin,  at  certain  points  covered  with  fibrinous 
exudate.  Sinus  very  near  labyrinth,  which  appears  nor- 
mal. Difficult  to  expose  the  posterior  fossa  in  front  of  the 
sinus,  because  the  sinus  lies  forward.  Bleeding  from  the 
slightest  injury.  Sinus  exposed  to  the  bend.  Packing  be- 
tween bone  and  the  bend.    Sinus  exposed  nearly  to  its  hori- 


164  DISEASES  OF  THE  LABYRINTH 

zontal  portion.  Pns  and  brain  substance  under  heavy  pres- 
sure are  pressed  out  as  the  bone  between  the  labyrinth  and 
sinus  is  removed.  Labyrinth  removed,  vestibule  and  cochlea 
opened.  Dura  of  posterior  fossa  is  incised.  Exploration  of 
brain  negative.  Brain  prolapsed  under  severe  pressure. 
Middle  fossa  explored;  negative.  Lumbar  puncture  yields 
a  purulent  fluid.  After  the  operation,  strong  ny.  to  the 
healthy  side.    Does  not  become  entirely  conscious. 

Feb.  2:  Deep  coma.  Slow,  deep  breathing.  6.30  P.M., 
death. 

Postmortem  (Prof.  Stoerk) :  Purulent  meningitis,  espe- 
cially of  base  (fibro-purulent).  Lobar  pneumonia,  with  in- 
dividual foci  in  each  lobe.  Acute  swelling  of  the  spleen. 
Cloudy  swelling  of  the  parenchyma.    Coronary  sclerosis. 

54.   Sch.  S.   Male.   Admitted  Mch.  29,  1908. 

Anamnesis:  Acute  otitis  1.  for  three  weeks,  but  he  has 
suffered  for  three  months  from  a  headache  following  a  fall. 
Headache  more  severe  since  the  otitis.  Paracentesis  in  our 
out-patient  department  one  week  ago,  with  relief.  Last 
night,  complained  of  severe  headache;  later,  became  un- 
conscious and  did  not  awaken. 

Status  praesens:  Unconscious.  Dyspnoea.  Temp.  40. 
Cannot  be  aroused.  No  restlessness.  Skin  pale,  face 
slightly  cyanosed.  Pupils  equal,  react  promptly.  Rigidity 
of  neck  not  noticeable.  Pronounced  dermography.  Re- 
flexes not  definite.  Kernig  test  seems  to  be  painful.  Ex- 
tremities, especially  the  lower  ones,  rigid.  Sphincters  re- 
laxed. L.e. :  Profuse  non-fetid,  yellow,  purulent  discharge. 
!Membrana  tympani  red  and  swelled.  Perforation  not  visi- 
ble. Cal.  react,  negative  1.,  on  r.  side,  prompt.  Cold  irri- 
gation causes  the  eyes  to  remain  in  r.  canthus,  with  rotat. 

ny.  1. 

Operation,  Mch.  29  (Ruttin) :  Cerebrospinal  fluid  milky. 
The  veiy  pneumatic  mastoid  is  opened.  Its  cells  filled  with 
pus  and  granulations.  Antrum  opened.  Sinus  exposed,  and 
is  normal,  slightly  filled  and  very  small.     Middle  fossa 


CASE  HISTORIES  165 

opened.  Dura  is  stretched,  but  looks  normal.  Radical  op- 
eration ;  tjTnpanic  cavity  filled  with  granulations.  The  cu- 
rette enters  a  cavity,  which  proves  to  be  the  labyrinth,  filled 
with  granulations.  Labyrinth  opened  from  behind,  without 
laying  bare  the  dura,  and  leaving  the  upper  pyramid  angle. 
The  labyrinth  is  filled  with  granulations.  No  labyrinthine 
fluid  comes  away.  Facial  twitching  twice  during  the  chisel- 
ing. Promontory  opened.  No  fluid.  Dura  of  the  middle 
fossa  is  incised.  No  fluid.  No  prolapse,  though  the  incision 
is  long.  No  plastic.  Packing.  Camphor  saline  infusion. 
Death  during  the  night. 

Postmortem,  Mch.  20  (Dr.  Erdhehn) :  Acute,  purulent, 
chiefly  basal  meningitis.  Cloudy  arachnoid  and  pia.  Ex- 
tensive adhesion  of  the  dura  to  the  cranial  vault,  with  multi- 
ple osteomata.  In  sigmoid  sinus,  liquid  blood.  Purulent 
bronchitis,  etc. 

55.  W.  J.  Age  62.  Admitted  Apr.  18, 1908. 

Anamnesis:  Attempted  suicide  one  week  ago.  Bullet 
from  revolver  penetrated  in  front  of  r.  ear.  Not  uncon- 
scious. After  two  days,  he  noticed  a  yellow  secretion  from 
r.  ear.  At  once  tinnitus.  Very  little  vertigo,  increased  by 
moving  in  bed.  Hearing  was  immediately  gone.  Prolonged 
pain  in  ear.    No  headache.    Pains  on  masticating. 

Status  praesens:  In  front  of  r.  ear,  bullet  wound,  form- 
ing scar,  with  skin  blackened.  Anterior  meatal  wall  granu- 
lating. Movement  of  jaw  causes  granulations  to  move. 
From  the  meatus  comes  much  purulent  secretion.  No  de- 
tails visible.  The  probe  comes  in  contact  with  a  hard  body 
lying  above  and  posteriorly.  Mastoid  slightly  tender. 
Temp.  37.6. 

Functional  test:  R. :  Con.v.  %  m. ;  whisp.  a.c.  Deaf  when 
tested  with  the  exclusion  apparatus.  W.  1.,  R.  negative, 
Sch.  shortened.  No  vertigo.  Spont.  rotat.  ny.  to  healthy 
side.  No  fistula  symptom.  Cal.  react,  negative  (1.  posi- 
tive). Tr.  1.  =  after-ny.  horiz.  r.  12".  Tr.  r.  =  after-ny. 
horiz.  1. 16". 


166  DISEASES  OF  THE  LABYRINTH 

Operation  {Bat any) :  Typical  radical  operation.  The 
bullet  lies  on  the  oval  window.  Hammer  and  anvil  are 
broken.  Promontory  is  intact.  Sinus  exposed  for  an  area 
the  size  of  a  pea,  lies  well  backward.  Tegmen  tympani 
broken  by  the  bullet.  A  broken-down  extradural  liaeraa- 
toma  reaches  to  the  superior  petrosal  sinus,  and  far  for- 
ward, so  that  the  tegmen  tympani  must  be  removed.  The 
dura  is  not  wounded.  Labyrinth  is  opened  posteriorly.  The 
vestibule  is  discolored  black  (old  hemorrhage).  Promon- 
tory is  opened.  No  labyrinthine  liquor  flows  away.  Probe 
introduced  into  the  vestibule  appears  in  the  oval  window. 
Dura  of  the  posterior  fossa  not  exposed.  Anterior  meatal 
wall  is  destroyed  and  granulating.  Broken-down  cartilage 
in  the  track  of  the  bullet  excised.  Mandibular  joint  not 
opened.     Plastic;  dressing. 

Apr.  19 :  Ny.  1.  has  diminished.    Some  headache. 

Apr.  25 :  Ny.  behind  opaque  spectacle  O.  Some  headache 
and  pain  in  ear.  Sleeps  poorly.  Abundant  purulent  dis- 
charge from  the  wound. 

May  3 :  Feels  comfortable.    Some  pain  in  the  wound. 

May  12 :  Daily  dressings.  Wound  granulating  up  to  the 
facial.    Entire  course  without  fever. 

56.   L.  B.  Age  23.   Female.   Admitted  May  6,  1908. 

Anamnesis:  L.e. :  Always  well.  Four  yrs.  ago,  furuncle 
in  r.  ear.  Past  four  months  pain  in  r.  ear.  Polyps  were 
removed,  then  followed  bad-smelling  discharge.  Pains  in 
back  of  head.  No  vertigo,  no  fever.  Hearing  very  bad  on 
r.  side. 

Status  praesens:  R.e. :  Drum  cloudy,  thickened.  Above 
posteriorly,  a  granulation,  apparently  coming  from  the  an- 
truip.  At  the  juncture  of  the  external  ear  with  the  head, 
a  depression  in  the  bone  the  size  of  a  bean,  covered  with  a 
scar,  but  of  normal  colored  skin.  Mastoid  process  normal. 
Temp.  36.2. 

Functional  test:  Con.v.  8  m.  (?).  W.  r.,  E.  — .  Ci  +, 
e*  +.    No  vertigo.    No  spont.  ny,    Cal,  react,  -f. 


CASE  EISTOFIES  167 

Radical  operation,  May  8:  Temp.  37.  Because  the  sinus 
was  well  forward  and  the  dura  low,  the  operation  was  diffi- 
cult. Both  structures  were  exposed.  On  smoothing  the  fa- 
cial ridge,  twitching  of  r.  facial  muscles.  At  the  close  of  the 
operation  the  r.  corneal  reflex  was  gone.  Plastic  after 
Panse. 

May  9 :  Elevation  of  temp,  to  37.6.  Large  ny.  r.  Com- 
plete facial  paralysis  r. 

May  9-12:  First  change  of  dressing.  Wound  bleeds. 
Details  not  visible.  Deaf  on  right  side.  No  cal.  react,  with 
cold  saline  irrigation,  at  which  time  the  spont.  ny.  did  not 
change  its  character. 

May  13:  Temp.  38.3. 

May  14:  Dressing.  No  caloric  react,  with  cold.  Wound 
covered  with  purulent  exudate.  Spont.  ny.  1.  much  less. 
Temp.  38.6.  Lumbar  puncture.  The  cerebrospinal  fluid 
in  all  three  test  tubes  very  cloudy.  Coverglass  specimen 
stained  with  methylene  blue  shows  many  polynuclear  leu- 
cocytes.   Morphine  0.01,  10  A.M. 

Operation  (Prof.  Urbantschitsch) :  Skin  incision  back- 
ward. The  sinus,  lying  far  forward,  is  now  exposed  for 
ly^  cm.,  and  the  dura  in  front  of  the  sinus  is  exposed.  Hori- 
zontal semicircular  canal  is  opened.  The  vestibule  is 
opened  from  behind  and  the  cochlea  from  in  front  by  re- 
moval of  the  promontory.  No  fluid  flows  away  on  opening 
the  labyrinth. 

May  15 :  Spont.  ny.  to  1.  decidedly  stronger. 

May  18:  Temp,  to  38.2. 

Postmortem  (Docent  Bartels) :  Acute  purulent  lepto- 
meningitis after  otitis  media  suppurativa  chr.  dextr.,  and 
radical  operation,  etc. 

57.  F.  S.  Age  19.  Waiter.  Admitted  July  15,  1908. 

Anamnesis :  Discharge  r.  ear  since  childhood.  No  treat- 
ment. No  subjective  symptoms.  Hears  fairly  well.  An  old 
apex  catarrh,  otherwise  well,  until  five  days  ago.    Then  he 


168  DISEASES  OF  THE  LABYRINTH 

noticed  that  he  could  not  bear  with  1.  ear;  felt  a  hammer- 
ing in  this  ear  and  had  severe  headache  from  the  forehead 
to  the  occiput,  "as  if  the  skin  were  being  pulled  off."  July 
14,  1908,  in  the  evening,  a  sudden  Attack  of  vertigo,  with' 
vomiting.  All  objects  seemed  to  move  about  him  from  left 
to  right.  Patient  had  to  hold  on  to  things  to  keep  from  fall- 
ing. In  bed,  the  vertigo  and  vomiting  were  better,  but  re- 
turned on  sitting  up  or  standing.  High  fever,  with  sweat- 
ing. Whistling,  ringing  and  hammering  in  the  I.e.,  con- 
tinuing for  hours,  with  short  pauses.  These  noises  less 
since  yesterday. 

Status  praesens:  Patient  appears  very  sick.  Old  tuber- 
culosis r.  lung.  Sensorium  free.  Patient  replies  promptly 
and  positively.  Suggestion  of  rigidity  of  neck.  On  ac- 
count of  pain,  patient  cannot  bring  knee  to  abdomen. 
Passive  movement  of  the  neck  is  free.  Reflexes  and  sensi- 
tiveness unaltered.  On  showing  his  teeth,  the  1.  angle  of 
the  mouth  does  not  move.  Retina  very  hyperaemic,  other- 
wise normal  (Dr.  0.  Rutt'in).  Motion  of  eyes  free.  Vision 
normal,  except  vertigo  prevents  reading.  He  lies  partially 
on  the  r.  side,  with  the  head  entirely  upon  the  right  side. 
Lying  on  the  left  side  provokes  severe  vertigo,  when  ob- 
jects swing  from  the  left  to  the  right.  After  a  short  time 
on  the  left  side,  emesis.  Likewise,  vertigo  and  vomiting  on 
sitting  up,  slight  improvement  when  eyes  are  closed. 
Spont.  horiz.  ny.  r.,  even  with  eyes  to  extreme  1.,  in  which 
position  there  is  some  rotat.  ny.  The  ny.  is  very  quick  and 
of  large  size,  so  that  even  with  the  eyelids  closed  we  can 
plainly  see  the  quick  movement.  The  1.  labyrinth  does  not 
respond  to  the  calor.  test.  Prolonged  irrigation  ^vith  warm 
water  at  48  "^  does  not  affect  the  ny. 

Functional  test:  Con.v.  heard  r.  ear  promptly.  L. 
(tested  with  exclusion  apparatus)  when  words  are  shouted; 
he  hears  some  numerals.  Whisp.  0.  With  conversation 
tube,  con.v.  and  shouting  are  not  perceived.  Lower  limits : 
ai  =  5".  BezoWs  a,:  8"  (normal  80"-90'0.  0  5", 
c:  8",  c*  and  c'  much  shortened.    W.  to  r.  from  every  part 


CASE  HISTORIES  169 

of  head.    Bone  conduction  (a^  16")  heard  from  1.  mastoid. 

Operation,  July  15  {Ernst  V  rh  ants  chit  sch) :  Typical 
radical  operation.  Anvil  carious  (long  process  gone). 
Hammer  gone.  Granulations  in  antrum  and  tube,  also 
cholesteatoma  tons  masses.  Promontory  noticeably  pale, 
with  a  blue  tinge  below.  Posterior  fossa  is  laid  bare  after 
completion  of  the  radical  operation.  Sinus  lies  relatively 
well  back.  Hemorrhage  from  sinus  embarrasses  the  work. 
Abundant  flow  of  cerebrospinal  fluid.  The  probe  is  passed 
from  behind  under  the  facial  into  the  tympanic  cavity.  In 
chiseling,  slight  facial  twitching.  Promontory  opened  with 
one  blow  of  the  chisel.    Cochlea  destroyed.    Dressing. 

July  16:  Subjectively  decidedly  better,  no  emesis.  Ap- 
pears better,  eyes  brighter.  Slight  facial  paresis  of  the 
upper  branch  (the  eye  can,  by  effort,  be  entirely  closed). 
A  somewhat  more  marked  paresis  of  the  lower  branch, 
which,  however,  was  present  in  a  slight  degree  before  the 
operation.    Appetite  poor. 

*  July  17 :  Subjective  condition  like  yesterday.  Facial  pa- 
resis the  same  (upper  division  better).  Spont.  ny.  practi- 
cally entirely  gone,  visible  only  on  looking  to  r.  Great 
thirst.    Slight  emesis. 

July  18-20:   Feels  comfortable.    Normal  progress. 

July  21 :  First  change  of  dressing.  Practically  no  pus. 
Wound  looks  very  well. 

July  22  to  31 :  Normal  course.    Transferred  to  O.P.  Dept. 

58.  L.  Sch.   Age  54.  Waiter.   Admitted  April  22,  1909. 

Anamnesis:  Two  years  ago,  some  tinnitus,  but  no  dis- 
charge. Eight  days  ago,  severe  pain  in  1.  ear,  followed 
three  days  later  by  discharge.  Since  then,  extreme  head- 
ache, prolonged  vertigo,  emesis  and  fever. 

Status  praesens:  R.e.:  Drum  and  function  normal.  L.e. : 
Membrane  red  and  swollen.  Perforation  not  visible ;  mod- 
erate, non-fetid  discharge.  Deaf  for  speech  and  tuning 
forks.  Cal.  react,  cannot  be  elicited.  Large,  most  marked 
spont.  ny.  rotat.  r.     Anisocoria   (left  pupil  smaller)  lids 


170  DISEASES  OF  THE  LABYEINTH 

painful.  Spinal  column  at  level  of  neck  sensitive  to  pres- 
sure and  painful  on  movement  of  bead.  Keflexes  greatly 
exaggerated.  Ankle-clonus.  Ataxia  of  upper  extremities. 
General  hyperaesthesia ;  calf  muscles  especially  sensitive. 
Kernig.    Dermography.    Temp.  38.8.    Pulse  130. 

Operation,  Apr.  22  {Rut fin) :  All  the  cells  of  the  pneu- 
matic mastoid  filled  with  pus.  Radical  mastoid  operation. 
Dura  of  the  middle  and  posterior  fossae  laid  bare.  Dura  is 
normal.  No  perforation  of  the  labyrinth  wall  to  be  discov- 
ered by  the  application  of  tonogen.  Typical  labyrinth  op- 
eration.   No  flow  of  labyrinthine  fluid. 

Apr.  23 :  ^leningitis  sjTnptoms  more  marked.  Ny.  rotat. 
r.     Temp.  39.7. 

Apr.  24:  Unconscious.     Temp.  39.8. 

Apr.  25:  Death. 

Postmortem  (Docent  Bartel)  :  Purulent  leptomeningitis 
(abundant  exudate  over  the  anterior  part  of  frontal  lobe, 
on  the  upper  convolution,  less  at  the  base),  etc. 

59.  J.  K.  XgQ  39.  Weaver's  helper.  Admitted  May 
4,  1909. 

Anamnesis:  Chronic  suppuration  during  past  eight 
years.  Eight  days  ago,  vertigo.  During  past  day,  continu- 
ous vertigo,  emesis  and  headache. 

Status  praesens:  L. :  Membrane  and  function  normal. 
R. :  Pus  and  granulations  fill  meatus.  Totally  deaf.  Ny. 
rotat.  1.  with  eyes  in  all  positions.  Cal.  test  not  demonstra- 
ble.   No  fistula  symptom.    Temp.  37.8. 

Operation,  May  4  {Bar any) :  Typical  radical.  Cholestea- 
toma in  antrum.  Fistula  in  horizontal  semicircular  canal. 
Facial  nerve  lies  exposed  above  the  oval  window.  Dura  of 
the  middle  and  posterior  fossae  and  the  sinus  all  laid  bare ; 
all  normal.  Typical  labyrinth  operation,  without  extensive 
exposure  of  the  posterior  fossa.  A  small  piece  of  the  facial 
ridge  is  broken  off,  so  that  the  facial  nerve  lies  exposed. 
No  visible  pus  in  the  labyrinth.  Facial  paresis.  Temp. 
37.6.    Normal  course. 


CASE  HISTORIES  171 

May  5 :  X}'.  somewhat  less.  Facial  paresis.  Temp.  37.6. 
Normal  course. 

May  14:  Discharged. 

60.  M.  H.  Age  26.  Female.  Admitted  May  13,  1909. 

Anamnesis :  Apr.  8,  following  a  cold  in  the  head,  pains 
in  I.e.  Apr.  12,  spontaneous  perforation.  Pains  stopped 
3-4  days  later.  Abundant  discharge,  but  no  further  symp- 
toms of  note,  so  that  the  patient  could  do  her  work.  May 
8,  A.M.,  severe  vomiting  of  bile-tinged  food  masses,  re- 
peated in  the  afternoon.  At  this  time  the  vertigo  was 
slight,  so  that  she  could  work.  May  9,  the  vomiting  became 
less,  but  the  vertigo  caused  her  to  stay  in  bed.  Vertigo  and 
emesis  continued  the  following  days.  Vomiting  stopped 
after  the  morning  of  May  13,  but  the  vertigo  continued, 
though  less  severe.  With  the  first  onset  of  the  vertigo  there 
was  an  apparent  movement  of  objects  to  the  right.  Patient 
says  there  was  a  swelling  behind  the  ear  in  the  beginning 
of  the  illness. 

Status  praesens:  R.e. :  Normal.  L.e. :  Profuse;  creamy, 
purulent  discharge.  In  the  posterior  meatal  wall  there  is 
a  circumscribed  swelling  the  size  of  a  pea,  granulating  on 
its  surface.  Pressure  here  causes  pus  to  exude.  Ap- 
parently a  perforation  in  the  inferior  anterior  quadrant. 
Skin  over  the  mastoid  normal. 

Functional  test:  For  speech  (tested  with  exclusion  ap- 
paratus) and  tuning  forks,  deaf.  Cal.  ny.  not  to  be  elicited 
on  1.  side.  Turning  ny.  1.  — .  Large  rolling  spont.  ny.  r. 
with  eyes  in  any  direction.  Fistula  symptom  — .  Severe 
vertigo.  Patient  stayed  under  observation  until  May  24, 
during  which  time  the  vertigo  and  the  rotat.  ny.  r.  dimin- 
ished, but  are  still  present.  Repeated  tests  of  hearing  and 
reactions  give  the  same  results. 

Operation,  May  24  (Prof.  U  rh  ants  chit  sch) :  Mastoid 
Xmeumatic.  Its  cells  filled  with  non-fetid  pus.  Typical  rad- 
ical. Labj^rinth  wall  inspected  after  application  of  tonogen. 
Oval  window,  over  which  lies  a  granulation,  is  empty.    The 


172  DISEASES  OF  THE  LABYRIXTn 

probe  enters  without  resistance,  bnt  produces  a  twitching 
of  the  face  muscles,  indicating  that  the  horizontal  portion 
of  the  nerve  is  exposed.  Dura  of  the  posterior  fossa  is  laid 
bare.  Typical  labyrinth  operation.  In  the  afternoon,  after 
the  operation,  ny.  rotat.  r.  moderate,  but  little  vertigo  and 
emesis.  Patient  lies  quietly  upon  her  back.  Slight  facial 
paresis. 

May  27 :  Patient  able  to  sit  up  without  vertigo.  Eotat. 
ny.  r.  on  looking  to  r.  and  forward.  Pulse  104,  strong  and 
regular.    No  fever. 

May  29:  First  change  of  dressing.  Wound  looks  well. 
Patient  discharged. 

June  9 :  Wound  healing.    No  vertigo.    At  no  time  fever. 

61.  L.  K.  Age  41/0.  Admitted  June  4, 1909. 

Anamnesis:  R.e.  affected  during  past  five  weeks.  Dis- 
charge supposedly  three  weeks.  Fever  39-40  during  past 
two  days,  and  child  highly,  irritable.  Frequent  emesis  dur- 
ing past  ten  days. 

Status  praesens:  Temp.  39.1.  Pulse  124.  Kernig. 
Slight  rigidity  of  neck.  No  Babinski.  Right  hyperaes- 
thesia,  reflexes  slightly  exaggerated.  Cerebrospinal  fluid 
cloudy.  L.  drum  normal.  R.  drum  red.  In  the  posterior 
segment  a  teat-like  swelling,  from  which  exudes  tenacious 
pus  through  a  paracentesis  wound  made  the  day  before  by 
the  attending  physician. 

Functional  test:  Hearing  test  impossible.  Large  rotat. 
ny.  1.    Cal.  react.  0.    Fistula  sympt.  0. 

Operation  {Buttin) :  Mastoid  pneumatic.  Cells  filled 
with  pus.  Dura  of  middle  and  posterior  fossae  laid  bare ; 
normal.  Labyrinth  operation.  Wound  inspected  after  ap- 
plication of  tonogen.  Fistula  visible.  Condition  unchanged 
after  operation. 

July  6 :  Death. 

Postmortem  (Dr.  Wiesner) :  Purulent  meningitis.  Strep- 
tococcus pyogenes  in  the  pus.  Cerebrospinal  fluid  shows 
grampositive  cocci  in  short  chains  and  many  leucocytes. 
Culture:  Streptococcus  pyogenes. 


CASE  HISTORIES  173 

62.  M.  Sch.  Age  14.  Admitted  Sept.  10, 1909. 
Anamnesis:   Since    early  childhood,  discharge  r.    Three 

weeks  ago,  discharge  became  more  abundant  and  a  painful 
swelling  appeared  behind  the  ear.  Slight  fever.  The 
mother  says  patient  had  vertigo  and  stumbled  in  the  morn- 
ing on  arising. 

Status  praesens:  L.e. :  Drum  retracted.  K.e. :  Back  of 
the  external  ear,  a  large  fluctuating  mass,  the  size  of  an 
apple,  covered  with  reddened  skin,  extending  forward  to  the 
zygoma  and  backward  to  within  two  finger-breadths  of  the 
median  line.  Skin  infiltrated  about  the  swelling.  Meatus 
filled  with  a  hard  polyp. 

Functional  test:  Con.v.  V2  d^-;  with  exclusion  apparatus 
applied  to  1.  ear,  deaf.  W.  r. ;  K.  and  Sch.  could  not  be 
tested.  No  vertigo ;  no  fistula  sympt.  Spont  ny.  rotat.  1. ; 
behind  the  opaque  glasses,  spont.  rotat.  ny.  1.  on  looking 
forward.  Cal.  react.  — .  Tr.  r.  =  aft«r-ny.  horiz.  1.  20". 
Tr.  1.  =  after-ny.  horiz.  r.  10".    Temp.  37.8. 

Operation  {Bdrdny) :  Abscess  opened.  Decomposed  pus. 
Radical  operation.  Black  fistula,  size  of  pinhead,  in  hori- 
zontal canal,  from  which  pus  pours  forth  on  slight  pressure- 
Typical  labyrinth  operation.  Facial  nerve  exposed  in  the 
region  of  the  facial  spur.  Twitching.  Sinus  laid  bare  2  cm. 
Its  wall  thickened,  covered  with  exudate.  Dura  of  poste- 
rior fossa  laid  bare,  but  not  that  of  the  middle  fossa.  Dress- 
ing. 4  P.M. :  Temp.  37.3.  Pulse  84.  Normal  course.  Temp, 
normal. 

Sept.  17:  First  change  of  dressing.  Comfortable.  Fa- 
cial intact.  Wound  looks  healthy.  Ny.  rotat.  1.  very  slight, 
but  distinct  behind  opaque  glasses. 

Sept.  24:  Discharged. 

63.  B.  Sch.  Age  14.  Admitted  Oct.  5,  1909. 

Anamnesis:  Tj^phoid  two  years  ago;  since  then,  1.  dis- 
charge. Recently,  headache  and  increased  discharge,  occa- 
sional vertigo.    No  emesis,  but  slight  fever. 

Status  praesens:  L.e.:  The  tympanic  mucous  membrane 


174  DISEASES  OF  THE  LABYRINTH 

in  part  granulated,  in  part  covered  with  epidermis.  No 
remains  of  drumhead.  Attic  suppuration.  R.e. :  Membrane 
retracted,  atrophic. 

Functional  test:  L.e. :  Con.v.  (with  exclusion  apparatus) 
20  cm.  W.  r.,  R.  — ,  Sch.  shortened,  d  — ,  c*  +  (when 
struck  with  metal).  No  vertigo,  no  spont.  ny.,  no  fistula 
sympt.    Cal.  react.  jDrompt.    R.e. :  Function  normal. 

Operation  {Ernst  Urbantschitsch) :  Typical  Stacke  op- 
eration. Carious  anvil  removed.  Horizontal  canal  and  fa- 
cial intact.    Facial  ridge  undisturbed.  Plastic  after  Panse. 

Oct.  6:  No  vertigo,  no  spont.  ny.  Slight  facial  paresis 
(eye  can  be  entirely  closed  with  effort).  Emesis  in  the 
morning,  once  in  the  afternoon.  No  appetite.  Sleep  broken. 
Complains  of  nausea. 

Oct.  7,  A.M. :  Vertigo  on  attempting  to  sit  up.  Vomiting 
with  nausea.  Spont.  ny  r.  (healthy  side)  slight.  Hears 
vowels  a,  i,  u  through  the  bandage  with  1.  ear  (exclusion 
apparatus  r.). 

Oct.  8:  No  change. 

Oct.  10 :  Somewhat  better.  Spont.  ny.  less.  Once  out  of 
bed. 

Oct.  11:  Decidedly  better.  First  change  of  dressing. 
Wound  healing  well. 

Oct.  20:  Feels  well.  Still  slight  facial  paresis.  Wound 
cavity  in  good  condition.  Sometimes  vertigo  upon  sudden 
movement.  Temp,  normal.  Transferred  to  O.P.  Dept.  for 
after  treatment. 

Operation,  Nov.  27  (Ernst  Urbantschitsch) :  Tj^Dical  in- 
cision. Dura  of  the  middle  fossa  and  the  sinus  lie  far  for- 
ward. Typical  labyrinth  operation.  Plastic  after  Panse 
without  sutures.  Bleeding  from  the  jugular  bulb  from  in- 
jury by  a  bony  fragment  while  chiseling  the  promontory. 
Controlled  by  packing.    Iodoform  wick  packing. 

Nov.  28:   Feels  comfortable.    Temp.  38.2. 

Nov.  29:  Feels  comfortable.  Spont.  ny.  rotat.  r.  No 
vertigo  while  lying  down;  and  when  sitting  up,  much  less 


CASE  HISTORIES  175 

than  before  the  operation.  Occipital  headache  decidedly 
less.     Temp.  37.6. 

Nov.  30  to  Dec.  2 :  General  condition  the  same.  Temp., 
Nov.  30,  normal;  Dec.  1,  38.0;  Dec.  2,  37.3,  38.7. 

Dec.  3 :  First  change  of  dressing.  Healing.  Temp.  39.2, 
39.6. 

Dec.  4:  Internal  exam.  (Dr.  Reitter) :  Nothing  to  ex- 
plain the  fever.    Better  after  irrigation.    Temp.  38.4,  39.6. 

Dec.  6:  No  headache;  vertigo  upon  sitting  up.  Spont. 
ny.  rotat.  r.    Temp,  normal. 

Dec.  8 :  Temp.  39.1.  Dressing.  Healing  normal.  Occipi- 
tal pains. 

Dec.  9:  Unchanged.     Temp,  normal. 

Dec.  10,  1909,  to  Jan.  16,  1910:  Condition  always  the 
same.  Much  pain  in  occipital  region,  occasional  vertigo, 
frequent  evening  rise  of  temp,  (to  38). 

Jan.  17,  1910:  Wound  very  satisfactory.  Transferred  to 
O.P.  Dept. 

64.  J.  W.  Age  21. 

Anamnesis:  Since  childhood,  discharge  from  r.  ear;  at 
times  had  treatment.  For  past  eight  days,  pain  in  ear  and 
mastoid.    No  fever;  no  vertigo;  no  emesis. 

Status  praesens:  R.e. :  Membrane  totally  destroyed. 
(Granulations  and  fetid  discharge.) 

Functional  test:  Con.v.  2  m.,  whisp.  15  cm.  (exclusion 
apparatus  1.).  W.  r.,  R.  — ,  Sch.  lengthened.  C,  +,  c^  +. 
Spont.  ny.  rotat.  1.;  no  fistula  sympt.  Cal.  react,  prompt. 
No  fever. 

Operation,  Nov  2  (Beck) :   Typical  radical  operation. 

Nov.  3 :  No  fever.    Feels  well. 

Nov.  4:  Temp.  39.8.  Spont.  ny.  rotat.  1.  (healthy  side) 
marked.  Deaf  for  speech  and  tuning  forks.  Cal.  react,  not 
demonstrable. 

Labyrinth  operation  {Bardny) :  Typical  labyrinth  opera- 
tion. Dura  of  the  posterior  fossa  and  the  sinus  laid  bare. 
No  pus  on  opening  the  labyrinth. 


176  DISEASES  OF  THE  LABYEIXTH 

Nov.  5:  Ny.  rotat.  1.  less,  but  distinct. 

Nov.  6:  Ny.  rotat.  1.  somewhat  stronger.    Emesis. 

Nov.  9:  Ny.  rotat.  1.  slight,  no  vertigo,  no  emesis.  Feejs 
well. 

Nov.  17 :  Transferred  to  O.P.  Dept.,  with  wound  granu- 
lating well. 

65.  L.  V.  S.   Gymnasium  professor. 

Anamnesis:  Twenty  years  ago  polyps  were  removed. 
Suppuration  ceased  for  five  years.  Then  recurrence  of  the 
discharge.  Constantly  treated.  Since  Jan.  10,  vertigo  with 
every  movement,  sometimes  even  when  lying  down.  Pa- 
tient noticed  quick  movements  of  the  eyes  to  both  sides, 
with  nausea.  No  fever,  but  a  chill  one  week  ago.  Immedi- 
ate operation,  therefore,  advised  by  his  physician. 

Status  praesens:  R.e. :  Drumhead  retracted  and  cloudy. 
L.e. :  Total  destruction  of  drumhead,  no  ossicles ;  thick,  hard 
granulations  appear  from  the  upper  posterior  meatal  wall. 
In  the  tympanic  cavitj',  as  far  as  this  is  visible,  low  granu- 
lations, with  pus  flowing  from  above.    No  pain  on  pressure. 

Functional  test:  L.e.:  Deaf  for  speech  and  tuning  forks. 
W.  in  head.  R.  oo  — ,  Sch.  lengthened  (transferred).  At 
the  present  time,  slight  vertigo.  Spont.  ny.  rotat.  r.  =  1. 
No  fistula  sympt.  No  cal.  react.  Tr.  r.  =  after-ny.  horiz. 
1.  15".  Tr.  1.  =  after-ny.  horiz.  r.  20",  without  vertigo. 
R.e.  Con.v.  3  m.,  whisp.  %  m.  R.  — ,  Sch.  lengthened ;  Ci  +, 
c^  +.  The  spont.  ny.  rotat.  r.  is  much  stronger  than  1. 
Romberg  ( ?) ;  on  walking,  a  deviation  to  the  1.  Patellar 
reflexes  exaggerated  on  both  sides;  no  difference  in  the 
sensitiveness.  Pupils  react  promptly  to  light  and  accom- 
modation. Head  movements  free  and  without  pain.  Temp. 
36.3.    No  ataxia  of  the  extremities. 

Operation,  Feb.  2  (Ruttin) :  Typical  radical  operation. 
Sinus  lies  well  for^^ard.  The  dura  is  exposed  over  the  teg- 
men  in  an  area  as  large  as  a  heller  piece  and  is  covered  with 
granulations.  In  the  horizontal  semicircular  canal,  a  fis- 
tula, 3  mm.  long,  whose  edges  are  covered  with  brownish- 


CASE  HISTOL'IES  177 

red  granulations  and  into  wLicli  the  probe  can  be  passed. 
Dura  of  the  posterior  fossa  laid  bare.  Typical  labyrinth 
operation.  Limited  space  makes  operation  difficult.  Laby- 
rinth is  opened  from  behind.  On  opening  the  cochlea,  there 
is  a  free  flow  of  clear  labyrinthine  fluid.  The  labyrinth 
probe  passed  completely  through.  Plastic  after  Pause. 
Metal  sutures. 

During  three  days  after  the  operation  there  is  an 
abundant  discharge  of  fluid.  Headache,  no  ny.,  no  vertigo. 
(In  spite  of  frequent  tests,  no  ny.  after  the  operation,  and 
the  vertigo  disappeared  at  once.) 

66.  K.  M.  Age  56.  Admitted  Apr.  23,  1910. 

Anamnesis :  Discharge  1.  for  ten  years.  For  three  years, 
fistula  symptom  present  (treated  by  his  physician).  Ear 
was  dry  for  one  year.  For  fourteen  days  vertigo,  and  on 
Apr.  22,  very  severe  vertigo  and  vomiting,  for  which  rea- 
son the  patient  was  referred  to  the  clinic  for  operation. 

Status  praesens:  L.e. :  Total  destruction  of  the  mem- 
brane. The  tympanic  wall  covered  with  thick  scales  of  epi- 
thelium. Tip  of  mastoid  sensitive  to  pressure,  likewise  the 
soft  parts  under  it.    Severe  pains,  vertigo  and  emesis. 

Functional  test:  Deaf  for  speech  and  tuning  forks,  E.  — , 
Sch.  shortened,  W.  in  head.  Spont.  ny.  to  healthy  side  (3rd 
degree),  no  fistula  symptom,  no  cal.  react.    R.e. :  Normal. 

Operation,  Apr,  24  (Bonclij) :  Bone  like  ivory,  very  hard. 
Antrum  of  medium  size.  In  the  tympanic  cavity  and  attic, 
abundant  cholesteatomatous  material.  In  the  prominence 
of  the  horizontal  canal,  a  fistula,  3-4  mm.  long,  with  black- 
ish edges.  Posterior  fossa  opened.  Dura  slightly  torn  by 
a  bone  fragment.  Free  discharge  of  fluid.  Bleeding  from 
sinus  stopped  by  packing.  Typical  labyrinth  operation. 
The  labyrinth  probe  is  easily  passed  through  the  oval  win- 
dow. Promontory  opened  and  cleaned  out.  Plastic. 
Dressing, 

Apr.  25:  No  fever.  Abundant  discharge  of  cerebro- 
spinal fluid. 


178  DISEASES  OF  THE  LABYRI\'rn 

Apr.  27:  Very  little  fluid  escapes.  Ny.  very  slight  and 
only  on  looking  toward  the  healthy  side.  Little  sleep,  be- 
cause of  headache.  Temperature  36.4.  Pulse  80,  regular. 
Movements  of  the  head  entirely  free.    No  rigidity  of  neck. 

Apr.  28 :  First  change  of  dressing.  Gauze  removed  from 
sinus  and  dura.  Very  slight  bleeding.  Cavity  of  wound 
shows  no  irritation.  P.M. :  Renewed  flow  of  small  amount 
of  fluid. 

Apr.  29 :  Flow  stopped.  Occasional  headache,  no  menin- 
gitis symptoms.    Evening:  Pyramidon  and  veronal. 

May  2:  Condition  the  same.  General  condition  good; 
occasionally  stands  up.  Still  a  trace  of  ny.  rotat.  r.  on  look- 
ing to  r.    Complains  only  of  vertigo. 

May  5:  Ny.  gone. 

May  6:  Because  of  erysipelas,'  isolated. 

May  9 :  Erysipelas  over  1.  eye. 

May  11:  Eye  examination  (Dr.  0.  But  tin) :  Tense 
oedema  of  both  eyelids,  completely  closing  the  left  one. 
Necrosis  of  the  skin  of  both  lids,  particularly  toward  the 
inner  canthus.  Slight  conjunctival  hyperaemia.  The  lower 
segment  of  the  cornea  infiltrated  and  nearly  devoid  of  its 
epithelium,  but  no  loss  of  substance.  No  oedema  of  the  con- 
junctiva.   Right  lid  the  same.    Eyeball  unaffected. 

May  25 :  Erysipelas  has  run  its  course.  Skin  scaly.  No 
loss  of  substance  on  the  lids  of  the  1.  eye,  which  are  begin- 
ning to  granulate.  Eyeball  intact.  Wound  granulating, 
abundant  discharge.    Dressed  every  other  day. 

May  30 :  Erysipelas  cured.    Transferred  to  O.P.  Dept. 

67.  A.  H.  Female.  Age  35  years.  Admitted  June 
19,  1910. 

Anamnesis:  Suppuration  for  more  than  five  years.  Com- 
plains of  severe  vertigo,  even  when  lying  down. 

Functional  test:  L.e. :  Deaf  for  speech  and  tuning  forks. 
Spont.  ny.  rotat.  r.  No  fistula  symptom.  Cal.  test  0. 
Temp.  37.6. 

Operation,  June  22    (Prof.   Urhantschitsch) :    Sclerotic 


CASE  HISTORIES  179 

mastoid  opened.  Dura  of  the  middle  fossa  lies  low  and  is 
covered  with  many  granulations.  Laid  bare  to  the  area  of 
a  heller  piece,  until  healthy  tissue  is  reached.  The  facial 
muscles  twitch  repeatedly  during  the  radical  operation,  the 
nerve  lying  exposed  under  the  horizontal  canal.  The  bone 
under  the  facial  nerve  is  removed,  and  the  labyrinth  is 
opened  from  behind.  Probe  passes  through  the  round  win- 
dow without  resistance.  Promontory  removed.  Plastic. 
Dressing. 

June  28 :  First  change  of  dressing.  Gauze  very  adherent. 
Dura  pulsates  very  noticeably.     Practically  no  free  pus. 

June  30 :  Since  two  days  ago,  some  ny.  rotat.  r.  No  ver- 
tigo ;  no  headache. 

July  20:  Tr.  r.  =  after-ny.  horiz.  1.  5".  Tr.  1.  =  ny. 
lioriz.  r.  10".  Transferred  to  O.P.  Dept.  No  more  vertigo, 
no  equilibrium  disturbances.  Some  spont.  ny.  rotat.  r. 
Free  from  fever  since  the  first  day. 

68.  J.  Z.  Male.   Age  23  years.    Admitted  July  2, 1910. 

Anamnesis:  Since  fifth  year,  discharge  from  I.e.  (after 
scarlet  fever),  which  has  continued.  During  the  past  eight 
to  fourteen  days,  headache  and  vertigo.  No  fever.  Patient 
noticed  that  during  past  two  weeks  the  left  side  of  his  face 
has  been  relaxed  and  that  he  could  not  close  the  1.  eye. 

Status  praesens:  R.e. :  Scar  in  posterior  superior  quad- 
rant. L.e. :  Two  large  polyps  obscure  nearly  the  entire 
drumhead,  except  a  small  red  area  of  the  superior  posterior 
quadrant.  Facial  paresis.  Skin  of  forehead  flaccid.  Slight 
loss  of  control  of  mouth  on  whistling,  and  1.  eye  cannot  be 
closed. 

Functional  test:  R.e.:  Con.v.  7  m;  whisp.  5-6  m.;  R.  +, 
Ci  +  c*  -h ;  spont.  rotat.  ny.  on  looking  to  r.  Fistula 
s}Tnpt.  0.  Cal.  ny.  -f.  L.e.:  Veiy  loud  con.v.  heard. 
AVhisp.  a.c.  Tinnitus  present.  W.  1.,  R.  — ,  Sch.  lengthened. 
Ci  +,  C*  still  by  bone  conduction.  Vertigo.  Spont.  ny.  O, 
fistula  sympt.  0.  Cal.  ny.  +,  but  of  short  duration,  with 
slight  vertigo. 


180  DISEASES  OF  THE  LABYRIXTH 

Operation,  Juh'  4  (Dr.  Froeschels) :  Bone  bard,  no  cells. 
Antrum  very  small,  filled  with  granulations.  Eadical  op- 
eration. Sinus  laid  bare  over  small  area ;  normal.  Plastic 
after  Panse. 

July  6 :  Dressing  wet.  Changed.  Eczema  of  external  ear 
and  the  adjacent  skin.  Drain  removed;  also  the  metal 
sutures. 

July  7:  Patient  comphiins  of  vertigo.  Bad-smelling  dis- 
charge comes  through  the  dressing.  Facial  as  it  was  be- 
fore the  operation.  Hearing  (tested  with  exclusion  appa- 
ratus) :  Perceives  loud  shouting  and  vowels.  Wound  nor- 
mal.   Eczema  unchanged.    Alcohol  compi  esses. 

July  9:  Eczema  improved.  Discharge  still  of  bad  odor 
and  free.    Zinc  salve. 

July  11:  Temp.  37.5.  Feels  well,  except  for  temp.  No 
headache  or  vertigo.  Hearing  tested  with  exclusion  appa- 
ratus and  with  dressing  off:  Loud  shouting  faintly  per- 
ceived. 

July  15:  Patient  complains  since  yesterday  of  nausea 
and  slight  headache.  Temp,  since  July  13  over  38.  This 
A.M.,  36.8.  Stronger  spont.  ny.  to  both  sides;  on  looking 
to  1.,  horiz.  ny  is  stronger  than  rotat.  ny.  on  looking  to  r. 
Hearing  doubtful.  No  cal.  react.  After  tr.  1.,  ny.  horiz.  r. 
30".  After  tr.  r.,  ny.  =  0.  No  fistula  symptom.  Wound 
secretes  abundant  bad-smelling  pus.    Eczema  better. 

July  19:  Dressing  changed.  Sudden  chill,  slight  head- 
ache ;  otherwise  condition  is  unchanged.  Slight  pleurisy  r. 
Thickening.    Fundi  normal. 

6  P.M.,  Operation  (Dr.  Riittin) :  The  granulations  cov- 
ering the  inside  of  the  wound  curetted  away.  Sinus  lies 
free  for  1  cm.  Covered  with  .grayish-red  granulations. 
Dura  of  posterior  fossa  laid  bare.  This  is  apparently  nor- 
mal. Inner  wall  of  tympanic  cavity  inspected.  Horizontal 
canal  smooth,  no  stapes,  but  in  its  place,  granulations. 
The  probe  passes  without  the  slightest  resistance  into  the 
oval  window.  Promontory  soft.  Labyrinth  opened  from 
behind.    The  chisel  goes  through  without  resistance.    Probe 


CASE  HISTORIES  181 

passed  behind  tlie  facial.  Dnra  of  middle  fossa  laid  bare; 
normal.  Sinus  laid  bare  for  more  than  21/0  cm.  Its  wall 
is  not  entirely  normal,  but  only  slightly  changed  by  slight 
grayish-red  exudate.  Wound  cleaned.  White  gauze 
packing. 

July  21:  Comfortable.  No  headache.  Pulse  84.  Ny. 
rotat.  r.  ==  1.  as  before,  slower  to  the  1.  and  more  rotatory. 
Pupils  equal,  and  react  promptly  to  light  and  accommoda- 
tion. No  headache  or  vertigo.  Lies  on  back.  Facial  pare- 
sis of  eye  and  mouth  inervation  as  before.  Abdominal, 
patellar  and  ankle  reflexes  well  defined.  No  ataxia.  No 
sensory  disturbances.  Mentality  normal.  Feels  well  ex- 
cept for  lack  of  appetite. 

July  22 :  Nj*.  as  before.    No  vertigo,  headache  or  emesis. 

July  23:  Dressing.  Wound  purulent  and  bad  smelling. 
HoOo  used.  Feels  well.  Ny.  rotat.  r.  =  1.,  the  latter  slower. 
No  headache,  vertigo  or  emesis. 

July  25:  Condition  of  lungs  as  before.  Internally,  no 
cause  for  fever.     (Dr.  BiacJi.) 

July  26:  Because  the  temperature  persists  and  is 
pyaemic  in  character,  and  the  neurological  and  internal 
findings  are  negative,  we  operated  again  in  the  evening 
{Ruttin).  Jugular  ligated  above  the  common  facial  vein. 
Jugular  normal,  filled  so  that  it  is  the  size  of  one's  thumb. 
Sinus  laid  bare  below  to  the  jugular  bulb,  above  to  beyond 
its  bend,  until  healthy  tissue  is  found.  Sinus  opened  and 
emptied  of  abundant  quantities  of  grayish-red,  fetid,  but 
not  discolored,  thrombi,  which  extend  from  the  bulb  to 
above  the  bend.  No  bleeding  from  below,  but  free  hemor- 
rhage from  above.    Packing  and  dressing. 

July  27 :  Fever  continues,  otherwise  patient  is  comforta- 
ble. Internal  findings  negative  (Dr.  Biach).  Stool  liquid, 
fetid. 

July  28:  Dressing,  Sinus  covered  with  yellowish-green 
exudate,  very  fetid.    Bleeding  from  upper  end  of  sinus. 

July  29 :  Slight  pain  in  r.  eyeball  and  slight  oedema  of 
the  conjunctiva.    Does  not  complain  of  pain.    Restless  at 


182 


DISEASES  OF  THE  LABYRINTH 


night.  Drowsy  by  day.  No  vertigo,  no  headache.  Pulse 
88.    Ny.  as  before. 

July  29,  Report  from  Institute  of  Pathology:  Thrombus 
from  sinus:  Masses  of  bacteria.  In  the  culture,  pseudo- 
diphtheria  and  proteus  (Dr.  Wiesner). 

July  30:  Dressing.  Sinus  covered  with  thick  exudate, 
very  fetid.  H2O2.  Still  bleeds  from  upper  end.  Jugular 
wound  clean.  Complains  of  pain  in  throat.  Slight  redness 
in  throat.    Otherwise  as  before.    Ny.  as  before. 

July  31 :  Eestless  at  night,  drowsy  by  day.  No  headache 
or  vertigo.  Ny.  as  before.  Pulse  84.  Neurological  exam, 
negative.  Dressing.  Sinus  covered  with  greenish-yellow 
exudate,  fetid ;  HoO..  Bleeding  from  upper  end.  Slight  pro- 
trusion of  r.  eyeball.  (Diagnosis:  Rapidly  developed  cav- 
ernous thrombosis.) 

Aug.  1 :  Dressing.  Sinus  as  it  was  yesterday.  H2O2. 
Protrusion  greater.    Oedema  of  both  lids  r. 


Fig.  25 


Aug.  2:  Dressing.  Sinus  as  before.  Manganese  perox- 
ide and  H2O2.  Condition  like  that  of  yesterday,  but  the 
protrusion  is  greater,  likewise  the  oedema  of  the  lids. 
Evening:  Electrargol  isoton.    5  c.c.  given  subcutaneously. 


CASE  HISTOKIES  183 

Aug.  3:  Death.    (See  temp,  chart.) 

Postmortem  (Prof.  Ghon) :  Purulent  basal  leptomenin- 
gitis and  pachymeningitis  interna,  especially  in  the  region 
of  the  posterior  fossa.  A  recent  abscess,  the  size  of  a  small 
cherry,  on  the  under  surface  of  the  1.  cerebellum.  Throm- 
bophlebitis of  the  sigmoid  sinus,  and  the  bulb  of  the  1.  side 
of  the  1.  inferior  petrosal  sinus  and  both  cavernous  sinuses. 
Kadical  operation  on  the  1.  side  on  account  of  chronic  otitis, 
with  opening  of  the  labyrinth.  Thrombi  in  the  peripheral 
section  of  the  veins  (sinuses)  named.  Acute  oedema  of  the 
lungs,  etc.,  etc.  Bacteriological  report:  In  the  exudate  of 
the  meningitis,  a  few  long  Gram-negative  threads. 

69.  H.  W.  Male.  Admitted  July  15,  1910. 

Anamnesis:  Since  childhood,  a  discharge  from  r.  ear,  to 
which  patient  attached  no  importance.  Three  weeks  ago, 
sudden  pains  in  the  diseased  ear,  with  intense  continuous 
headache  and  complete  loss  of  appetite.  Three  weeks  ago, 
had  such  severe  vertigo  that  he  could  not  leave  his  bed  and 
recognized  nobody.  Also  severe  emesis.  Now  some  ver- 
tigo, but  not  so  much.    Temp.  39.2.    Pulse  104. 

Status  praesens:  Patient  sits  moaning,  with  head  bent 
forward.  Every  movement  is  painful.  On  attempting  to 
put  the  head  upright  by  passive  movement,  he  feels  severe 
pains  in  the  neck,  where  there  is  a  pronounced  rigidity. 
Passive  movements  of  the  head  laterally  are  also  impossi- 
ble. Pupils  alike,  and  react  to  light  and  accommodation. 
Abducens  paralysis  1.  Facial  intact.  Abdominal  reflexes 
strong  and  nearly  equal.  Patellar  reflexes,  especially  1.,  ex- 
aggerated. Suggestion  of  ankle  clonus.  Kernig  and 
Babinski  positive.  L.e. :  Normal.  E.e. :  Meatus  narrow, 
drum  destroyed.  A  polyp  protrudes  from  the  antrum, 
which  is  discharging  pus  which  shows  pulsation. 

Functional  test:  E.e.:  Deaf  for  speech  and  tuning  forks. 
Tinnitus.  W.  indefinite.  K.  oo  — ,  Sch.  shortened.  No 
spont.  ny.  No  fistula  sympt.  Cal.  react,  cannot  be  demon- 
strated. 


184  DISEASES  OF  THE  LABYRIXTH 

Operation  {Bondy) :  Very  hard,  sclerosed  bone.  In  the 
antrum,  whose  walls  are  smooth  like  ivory,  foul-smelling, 
thin,  brownish  pus.  Posterior  fossa  opened.  Sinus  and 
dura  of  the  cerebellum  discolored  over  a  wide  area,  thick- 
ened and  covered  with  granulations.  Typical  labyrinth  op- 
eration. Some  liquid  flows  from  the  labyrinth  at  the  close 
of  the  operation.  Exploration  of  the  cerebellum  in  differ- 
ent directions  is  negative.  Dura  of  the  middle  fossa  widely 
incised.  No  plastic.  Sinus  not  opened,  in  spite  of  altered 
wall.  Dressing.  Lumbar  puncture.  Cerebrospinal  fluid 
equally  cloudy  in  all  three  portions. 

July  16:  A.M.,  temp.  37.8.  Sensorium  like  yesterday, 
somewhat  dull.  Reacts  when  addressed  with  loud  voice. 
No  ny. 

July  18:   7  P.M.,  death. 

Postmortem  (Prof.  Ghon) :  Recent  fetid  leptomeningitis 
and  internal  pachymeningitis  of  the  posterior  portion  of 
base  of  brain,  in  addition  to  an  older  leptomeningitis  in  the 
•1.  Sylvian  fissure  and  on  the  1.  convexity  of  the  cerebrum; 
acute  internal  hydrocephalus,  fresh  subdural  hemorrhage 
in  the  region  of  the  convexity  and  of  the  base,  after  inci- 
sion of  a  vein  in  the  dura  over  the  right  petrosal  bone.  In- 
cision of  the  lateral  pole  of  the  posterior  occipital  lobe,  and 
a  small  incised  wound  of  the  right  parietal  lobe.  Radical 
operation,  with  labyrinth  operation  of  r.e.  A  fetid  abscess, 
the  size  of  a  small  bean,  in  the  posterior  part  of  the  infe- 
rior lobe.  Diffuse  bronchitis,  confluent,  lobular  pneumonia 
foci.    Atalectases  in  the  posterior  parts  of  both  lungs. 

70.  J.  D.  Age  18.  Admitted  Feb.  23,  1910. 

Anamnesis:  Discharge  from  I.e.  since  childhood,  follow- 
ing measles.  Conservative  treatment  since  middle  of  Jan- 
uary, without  results,  for  which  reason  the  radical  opera- 
tion was  performed,  Feb.  11,  in  the  sanatorium  (Bondy). 
Sinus  exposed  over  a  small  area,  dura  of  the  middle  fossa 
widely  exposed.    Both  normal.    Panse-plastic. 

Feb.  12:  Temperature  rises  to  38.3.     Slight  vertigo  on 


CASE  HISTORIES  185 

turning.  Ny.  to  the  healthy  side,  disappears  on  looking 
to  diseased  side.  Evening:  Change  of  dressing.  Hears 
spoken  voice,  but  does  not  understand.  Middle  fork  heard 
1.  Irrigation  with  hot  water  has  no  effect.  Dressed  with 
xeroform  gauze. 

Feb.  13 :  Ny.  somewhat  less.  Otherwise  condition  is  the 
same.    Cal.  test  gives  no  response.    Temp.  37.6,  38.3. 

Feb.  14:  Ny.  only  on  looking  to  the  healthy  side.  Irri- 
gation with  cold  water  greatly  intensifies  the  ny.  Temp. 
37.5,  38.0. 

Feb.  15  and  16:  Condition  the  same.  Temp.  37.3,  37.6. 
Feb.  17 :  Normal  temp.  Ny.  on  looking  to  healthy  side  is 
noticeable. 

To  Feb.  21 :  Normal  temp.  Daily  dressing.  Discharged 
from  the  sanatorium. 

Feb.  22 :  Temp,  elevation  to  37.4.  Severe  headache.  Can- 
not sleep. 

Feb.  23 :  Condition  the  same.  Transferred  to  the  clinic. 
Ophthalmoscopic  findings  normal  (0.  Rutfin).  Pupils 
equal,  react  promptly.  No  Kernig,  no  increased  reflexes. 
No  hyperaesthesia.  Dressing  changed.  Labyrinth  not  af- 
fected by  hot  or  cold  irrigation.  L.e. :  Total  deafness. 
Temp.  37.8. 

Feb.  23,  Labyrinth  operation:  Typical.  Oval  window 
appears  to  be  empty,  for  the  probe  enters  easily.  Dura  of 
the  cerebellum  laid  bare  from  the  exposed  sinus.  The  bone 
covering  the  superior  petrosal  sinus  was  left  untouched. 
Vestibule  widely  opened.  Facial  twitching  once  during  the 
operation.  In  the  angle  between  the  dura  of  the  cerebellum 
and  the  facial  nerve,  below  the  vestibule,  there  is  a  granula- 
tion extending  into  the  vestibule  (perilabyrin thine  cell). 
The  dura  of  the  cerebellum  distinctly  discolored  a  brownish- 
red.  Incision  here  with  puncture  of  the  cerebellum  with 
the  brain  knife  gives  a  negative  result.  Horizontal  incision 
sewed.    Dressing. 

Feb.  24:    Moderate  pains  in  the  wound.    Head  free; 
vomited  once.    Ny.  unchanged.    Temp.  36.0-37.2. 


186  DISEASES  OF  THE  LABYL'lM'n 

Feb.  25 :  Xy.  chiefly  lioriz.  to  healthy  side,  more  strongly 
rotat.  to  diseased  side ;  vertical  ny.  on  looking  upward.  De- 
cided headache.  No  stool  for  three  days.  Enema  with 
good  results.  Dressing.  Wound  shows  nothing  unusual. 
Eczema  of  pinna.  Alcohol  dressing.  Pulse  68.  Temp.  37.4, 
36.0. 

Feb.  26:  Unable  to  sleep  because  of  headache.  Ny.  un- 
changed. Objects  held  to  1.  of  patient  he  is  unable  to  fix 
for  any  length  of  time  (fixation  paresis  1.  ?).  No  diplopia. 
Dressing.    Frequent  emesis.    Pulse  64.    Temp.  37.7,  37.2. 

Feb.  27 :  Again  unable  to  sleep  on  account  of  headache. 
Pulse  60.  Diplopia  on  looking  to  the  1.  Dressing.  Incision 
of  the  cerebellum  opens  an  abscess,  from  which  a  table- 
spoonful  of  thick,  creamy  pus  flows.  Drainage  with  iodo- 
form gauze  soaked  in  HoOo.  After  the  incision,  almost  im- 
mediate disappearance  of  the  headache.    Pulse  66.    Temp. 

36.2  to  37.6.    P.  M. :  Temp.  37.6.   Pulse  90.    No  more  emesis, 
no  headache. 

Feb.  28:  Report  from  the  Pathological-Anatomical  In- 
stitute on  pus  from  the  cerebellum :  Streptococcus  pyogenes 
(Dr.  Bartel).  Slight  headache  during  the  night.  Dressing. 
A  rubber  drain  introduced  into  the  abscess  cavity.  Pulse 
72.  Evening:  Dressed  again,  on  account  of  severe  head- 
ache. Ophthalmoscopic  exam.  (Dr.  0.  Ruttin) :  Fundus 
normal.    Temp.  36.6  to  37.0. 

Mch.  1:  Slept  until  2  A.M.,  then  awoke,  but  without 
pain.  Pulse  84.  Dressing.  Abscess  cavity  irrigated  with 
H2O2.  Drainage,  pains  for  one-half  hour.  Then  no  pain. 
Appetite  good.    Evening:  Feels  well.    Temp.  36.3  to  37.4. 

Mch.  2:  Severe  headache  during  the  night;  vomited  three 
times.  Dressing.  Little  pus,  but  upon  entering  the  cav- 
ity with  the  dressing  forceps,  a  large  amount  of  pus  comes 
from  the  cavity.  Headache  is  at  once  less.  Irrigation  with 
H2O2.  A  strip  of  iodoform  wick  is  introduced.  T)i]ilopia 
is  less.    Slight  headache  in  the  evening.    Dressing.    Temp. 

36.3  to  36.9. 


CASE  HISTOBIES  187 

Mcli.  3 :  Slept  well,  appetite  good ;  no  more  diplopia. 
Pulse  100.    Dressing.    Temp.  36.0-37.1. 

Mch.  4 :  Feels  entirely  well.  Dressing  twice  a  day.  Ex- 
cellent appetite ;  sleeps  well.    Temp,  normal. 

Mch.  5 :  Condition  the  same.  Ny.  appreciably  less,  but 
still  pronounced,  and  horiz.  ny.  to  both  sides,  vertical  ny.  on 
looking  up  or  down. 

Mch.  9:  Some  headache  in  the  morning.  On  changing 
dressing,  some  retention  of  pus  evident.  Drained  with  iodo- 
form gauze  (heretofore  iodoform  wick  had  been  used). 
Evening,  free  from  headache.  Ny.  as  before,  but  decidedly 
less.    "Wishes  hot  food. 

Mch.  12:  Up  to  this  morning,  felt  entirely  well.  On 
changing  dressing,  immediately  after  irrigation  of  the  cav- 
ity with  II.Oo  (which  heretofore  has  always  been  well  tol- 
erated), there  is  very  severe  headache.  No  retention  of  pus 
evident.  Ate  well  at  noon,  but  soon  vomited  it  all.  P.M. : 
Increasing  headache.  On  changing  dressing,  nothing  un- 
usual, and  no  pus.  Puncture  of  the  cerebellum  in  various 
directions  is  without  result.  Emesis  after  the  dressing. 
Pulse  57.    Arythmic.    Left  abducens  paralysis. 

Mch.  13:  5.30  P.M.,  death. 

Postmortem  (Prof.  Glion) :  A  hemorrhagic  abscess,  about 
the  size  of  a  small  nut,  in  the  1.  cerebellar  lobe,  embracing 
nearly  all  of  the  central  portion,  about  to  perforate  at  the 
posterior  pole.  Puncture  of  the  abscess  and  drainage  with 
gauze  (Feb,  27);  radical  operation  1.  (Feb.  10);  labyrinth 
operation  (Feb.  23) ;  recent  puncture  of  the  1.  cerebellar 
hemisphere  (Mch.  12).  Circumscribed  lepto-  and  pachy- 
meningitis interna  on  the  posterior  portion  of  the  petrosal 
bone,  with  adhesion  of  the  left  cerebellar  hemisphere  in  this 
region.  Internal  hydrocephalus  and  a  few  hemorrhagic 
points  in  the  ependyma  of  the  lateral  ventricle.  General 
hyperaemia  of  the  internal  organs.  Hyperplasia  of  the 
lymi)hatic  tissue  of  the  mouth  and  pharynx,  of  the  splenic 
follicles  and,  in  a  limited  way,  of  the  follicles  of  the  small 
intestines.    Colloid  struma.    Open  foramen  ovale. 


188  DISEASES  OF  THE  LABYRINTH 

Bacteriological  report:  1.  Haemorrhagic  exudate  of  the 
cerebellar  abscess.  Abundant  and  exclusively  grampositive 
cocci  of  the  streptococcus  pyogenes  type.  2.  The  contents 
of  the  lateral  ventricle,  sterile. 

71.    J.  R.    Age  14.    Apprentice.    Admitted  Oct.  3, 1907. 

Anamnesis:  Discharge  from  r.e.  at  age  of  10,  following 
scarlet  fever  and  diphtheria.  This  lasted  a  couple  of  years. 
One  month  ago,  a  free  discharge  began.  Two  weeks  ago, 
patient  had  vertigo,  when  objects  seemed  to  move;  his  gait 
was  somewhat  unsteady;  there  was  emesis,  headache  and 
lancinating  pains  behind  the  ear.  Hearing  was  not  noticea- 
bly diminished.  The  same  manifestations  again  appeared 
three  days  ago.  Hears  well  on  1.  side.  Says  he  has  always 
been  well. 

Status  praesens:  Mastoid  process  not  swelled  or  sensi- 
tive to  pressure.  Infra-auricular  gland  somewhat  painful 
on  pressure.  Large  perforation  in  drumhead,  with  whitish 
polyp,  posteriorly  located. 

Functional  test:  E.e. :  Con.v.  2  m.,  whisp.  0,  c^  — ,  Ci  -f, 
when  struck  hard.  Spont.  ny.  to  1.  on  looking  forward  and 
to  the  1.  Fistula  sympt.  negative.  Test  with  conversation 
tube,  con.v.  without  error.  Whisp.  not  heard.  After  tr.  1. 
ny.  horiz.  r.  5" ;  after  tr.  r.  horiz.  ny.  1.  30".  After  tr.  L,  with 
head  bent  forward,  ny.  rotat.  r.  8" ;  after  tr.  r.,  head  inclined 
forward,  ny.  rotat.  1.  22".  After  irrigation,  r.  ear,  with  2 
bags  of  cold  water,  only  slight  ny.  1.,  no  stronger  than  the 
existing  spont.  ny.    Temp.  37.8. 

Radical  operation:  After  opening  the  mastoid,  granula- 
tions appear  in  the  tympanic  cavity  and  antrum ;  also  dis- 
eased cells  in  the  posterior  superior  angle  of  the  mastoid. 
No  cholesteatoma.  No  fistula  to  be  seen.  The  region  be- 
tween the  three  semicircular  canals  is  very  carefully  cleaned 
out  and  inspected.  After  making  smooth  the  surface  of  the 
wound,  plastic  closure  (Neumann)  is  made. 

Oct.  4:  About  midnight,  temp.  39.0.  This  morning,  38.9. 
Patient  is  noisy,  tosses  about  in  bed,  face  drawn  with  pain. 


CASE  HISTORIES  189 

Complains  of  headache,  frequent  vomiting.  Pulse  80.  Ir- 
ritable.   Kernig  +. 

Operation:  Wound  opened.  Sinus  lies  well  forward. 
Cochlea  opened.  Facial  is  intact.  Dura  of  the  middle  and 
posterior  fossa  opened.  Drainage.  Wound  cleaned  and 
dressed.  On  opening  the  softened  promontory  and  the 
vestibule,  no  labyrinthine  fluid  escaped. 

Oct.  5:  Patient  feels  better.  Less  emesis  and  normal 
temp.  Headache  is  better.  No  vertigo.  Pulse  72.  At  1 
P.M.,  he  has  fever  (38.4)  and  pains  in  the  head  and  sacrum. 

Oct.  6:  Patient  has  some  fever,  less  headache.  Com- 
plains of  pain  in  sacrum  and  in  both  feet,  which  are  not 
swelled  or  sensitive  to  pressure.  No  vertigo.  Ny.  r.,  which 
was  not  present  yesterday.  Dressed  1  P.M.  No  discharge. 
On  pressing  on  the  dura  of  the  middle  fossa,  there  is  bleed- 
ing from  the  petrosal  sinus.    Temp.  38.3. 

Oct.  7,  A.M.:  Kernig  +•  Some  restlessness.  Pulse  82. 
Ny.  to  the  healthy  side,  none  to  the  diseased  side.  Temp. 
37.0.  Pain  in  the  legs  on  movement.  Slight  headache.  No 
disturbances  of  co-ordination.  Ophthalmoscopic  exam, 
shows  the  papilla  swelled,  with  outlines  somewhat  indis- 
tinct; veins  somewhat  widened  and  tortuous.  This  condi- 
tion is  more  pronounced  in  the  r.  eye  than  in  the  1. 

Oct.  8,  A.M. :  Slept  little  during  the  night ;  was  very  rest- 
less. Pulse  72.  Ny.  to  both  sides.  Evening:  Ny.  r.  Fa- 
cial paralysis  r.  in  all  divisions.  K.  angle  of  mouth  twitches. 
Unconscious,  delirious.  Dressing.  Wound  clean.  Explora- 
tory incision  of  the  parietal  lobe  and  the  cerebellum  through 
the  previous  wounds;  the  parietal  lobe  cut  in  three  direc- 
tions.   Death  the  same  day. 

Postmortem,  Oct  9 :  Basal  meningitis,  with  severe  oedema 
of  the  brain.  Left  petrosal  trephined.  Sinus  empty. 
Lobar  pneumonia.  Haemorrhagic  foci  in  both  lungs. 
Fatty  degeneration  of  parenchyma  of  internal  organs. 
Dilatation  of  ventricles.  Diplococcus  pneumoniae  in  the 
exudate. 


190  DISEASES  OF  THE  LABYRINTH 

72.    M.  R.    Age  6.    Admitted  Jan.  13,  1908. 

Anamnesis:  For  several  years,  a  fetid  discharge  from  1. 
ear.    Face  distorted  for  two  weeks. 

Status  praesens:  R.e. ;  Normal.  L.e. :  Slight  postauricu- 
lar  swelling  without  fluctuation.  Pus  and  cholesteato- 
matous  masses  in  the  canal,  which  is  filled  in  its  lower  part 
with  granulations. 

Functional  test:  Deaf  for  speech  and  tuning  forks.  Cal. 
react,  not  demonstrable.  Tr.  r.  =  0.  Tr.  1.  =  prompt  ny. 
r.  No  fistula  symptom.  Spont.  ny.  rotat.  r.,  but  slight. 
W.  r. 

Operation,  Jan.  14  (Ruttin) :  T3'pical  incision  through 
the  skin  and  infiltrated  tissues.  The  knife  enters  a  depres- 
sion in  the  upper  end  of  the  wound.  After  pushing  aside 
the  periosteum  there  appears  a  cavity  the  size  of  a  walnut, 
filled  with  movable  sequestra,  abundant  granulations, 
cholesteatomatous  layers  and  fragments  and  some  very 
fetid  pus.  The  rough,  unrecognizable  sequestra,  covered 
with  poorly  defined  granulations,  are  removed.  Three  of 
them  measure  from  one  to  four  cm.  in  their  greatest  diame- 
ter. The  resulting  cavity  is  the  size  of  a  hen's  egg.  The 
dura  of  the  middle  fossa  lies  exposed  from  the  carotid  canal 
to  the  sinus  and  from  the  upper  angle  of  the  pyramidal  bone 
to  the  squamous;  further,  a  strip  of  the  dura  of  the  poste- 
rior sinus,  lyo  to  2  cm.  long,  lies  exposed  in  front  of  the 
sinus.  The  dura  of  both  fossae  is  everywhere  thickened, 
grayish-red.  In  the  region  of  the  sinus,  many  fuugTis-like 
granulations  are  removed.  The  sinus  is  laid  bare  until 
healthy  tissue  is  reached.  There  remains  of  the  pyramid 
only,  its  posterior  and  lower  walls  and  a  portion  of  bone, 
which  may  contain  the  facial  nerve.  At  the  site  of  the  laby- 
rinth there  is  a  smooth-walled  cavity  the  size  of  a  hazelnut. 
Plastic  after  Panse.    Dressing. 

Jan.  20:  First  dressing.  Granulating.  No  discharge. 
Facial  paresis  the  same. 

Feb.  4:    Dressing  every  other  day.    Wound  granulating 


CASE  HISTORIES  191 

nicely.    Abundant  discharge,  not  fetid.    Bronchitis.    Facial 
paresis  the  same.    Dressing  every  other  day. 

Feb.  17 :  Wound  granulating  well.  Its  lower  angle  still 
open.    Borated  alcohol.    Allowed  to  go  home. 

73.  K.  F.  Age  22.  Male.  Admitted  Apr.  8,  1908. 

Anamnesis:  No  children's  diseases  recalled.  The  r.e. 
has  run  since  childhood,  but  patient  knows  no  cause.  No 
treatment  until  six  to  eight  weeks  ago.  Never  had  earache ; 
no  vertigo,  emesis  or  headache.  The  discharge  has  been 
constant  and  always  veiy  bad  smelling.  Six  weeks  ago,  in- 
fluenza, following  a  cold.  Then  he  noticed  no  unusual  ear 
symptoms;  the  discharge  was  the  same  as  before.  Head- 
ache, especially  at  the  vertex,  but  also  radiating  forward 
and  backward.  Emesis  once,  three  weeks  ago.  For  two 
weeks,  vertigo,  especially  on  walking,  with  a  sensation  of 
falling  backward.    Chills  and  fever  during  jDast  2-3  weeks. 

Status  praesens:  Patient  complains  continuously  of  pain. 
Sensitive  to  percussion  in  the  region  of  the  vertex.  Mas- 
toid, especially  at  the  tip,  very  sensitive  to  pressure.  Head 
can  be  moved  actively  and  passively  with  slight  pain.  Cer- 
vical spine  sensitive  to  pressure.  Pupils  equal  and  of  me- 
dium size;  react  promptly.  Eye  muscles  move  freely.  K. 
papilla  distinctly  hyperaemic,  with  slight  oedema.  Facial : 
Right  upper  lid  lags  somewhat,  but  only  noticeable  when 
he  is  told  to  close  his  eyes  slowly  with  head  bent  backward 
as  far  as  possible.  Tongue  is  promptly  protruded.  Grip 
strong  and  practically  equal.  Patellar  reflex  present,  pos- 
sibly exaggerated.  No  foot  clonus,  no  Babinski.  Deep  re- 
flexes of  the  upper  and  lower  extremities  present.  Cremas- 
teric reflex  alike  on  both  sides.  Walks  well  with  eyes  open, 
a  slight  tendency  to  fall  with  eyes  closed.  A  suggestion  of 
Romberg.  Stands  poorly  on  one  foot  with  eyes  open,  im- 
possible with  eyes  closed.  No  disturbances  of  sensory 
nerves.  Trousseau  very  plainly  -f .  Kernig  0.  Pulse  92, 
Temp.  38.3.  Heart :  Second  aortic  sound  accentuated.  R.e! : 
Superior  posterior  meatal  wall  bulged.     Canal  filled  with 


192  DISEASES  OF  THE  LABYFIXTH 

a  polyp  with  broad  base.  L.e. :  Membrane  looks  normal,  but 
lias  small  perforation  in  Shrapnell's  membrane.  No  dis- 
charge, but  a  few  lamellae  of  epidermis;  probe  can  be  in- 
troduced into  the  attic. 

Functional  test:  E.e. :  Con.v.  i/o  m.,  whisp.  a.c. ;  tested 
with  exclusion  apparatus,  deaf.  R.  — ,  Sch.  shortened. 
W.  1.,  Ci  0,  c^  +,  when  struck  hard.  Spont.  ny.  rotat.  r. 
Cal.  react.  — .  Middle  fork  heard  only  13"  after  being 
struck  hard. 

Operation  (Ruttin) :  Mastoid  sclerosed.  Antrum  opened 
simultaneously  with  removal  of  the  bridge.  Antrum  filled 
with  sticky,  yellowish-green,  very  fetid  cholesteatomatous 
fragments,  which  are  removed.  The  anterior  bony  wall  of 
the  external  canal  is  thickened  with  hyperostoses,  making 
the  tympanic  cavity  narrow.  The  inferior  wall  is  likewise 
thickened.  Typical  radical  operation.  Transverse  incision 
backward.  Sinus  laid  bare  2  cm.  Its  wall  is  normal.  In 
the  horizontal  semicircular  canal,  a  fistula,  the  size  of  a  pin- 
head,  with  edges  discolored  black.  Also  a  fistulous  passage 
in  the  labyrinth  nucleus  between  the  canal  and  the  facial 
prominence,  leading  in  the  direction  of  the  posterior  semi- 
circular canal.  In  following  this  passage,  we  actually  come 
upon  the  posterior  semicircular  canal,  which  has  a  fistula. 
The  entire  bone  up  to  the  dura  is  soft  and  diseased.  Typi- 
cal labyrinth  operation.  Vestibule  is  opened  from  behind. 
The  probe  enters  the  fossa.  In  following  up  the  fistulous 
passage  above  mentioned,  there  is  twitching  of  the  facial 
muscles,  but  this  is  unavoidable,  as  the  diseased  bone  in  the 
region  must  be  removed.  The  dura  of  the  posterior  fossa 
at  several  points  presents  single  grayish-red  granulations. 
The  cochlea  is  opened  from  the  promontory.  Plastic  after 
Panse.    Dressing. 

Apr.  9:  Decided  improvement.  Patient  complains  of 
only  slight  headache.  Appetite  good.  No  emesis,  no  ver- 
tigo.   Ny.  rotat.  r.  =  1. 

Apr.  10:  Improvement  continues.  Patient  complains 
only  slightly  of  headache;  is  quite  lively.    No  vertigo,  no 


CASE  JJISTOBIES  193 

sjTiiptoms  of  any  kind.  Ny.  rotat.  r.  =  1.,  less  than  j^ester- 
day.  Neurological  report  (Primaerarzt  Infeld)  negative. 
No  fever.    Pulse  84. 

Apr.  18:  During  the  following  days,  feels  well.  Ny.  to 
the  affected  side  is  still  present,  but  diminishing.  A  varia- 
bility in  the  intensity  was  not  noticed.  Vertigo  and  dis- 
turbances of  equlibrium  not  present,  though  patient  com- 
plains of  headache,  particularly  in  the  evening.  Nothing 
unusual  at  time  of  dressing.  Some  discharge  in  the  tym- 
panic cavity,  which,  ^vith  the  retrolabyrinthine  wound, 
shows  beginning  granulation. 

Apr.  23:  Dressing.  Very  little  discharge.  No  headache; 
ny.  rotat.  r.  =  1.,  and  very  slight. 

Apr.  25 :  Discharged. 

74.  H.  J.  Age  58.  Musician.  Admitted  Apr.  30,  1908. 

Anamnesis-:  Chr.  suppuration  1.  Facial  paralysis  for 
three  weeks.  Deafness  1.  No  vertigo.  Some  headache,  no 
emesis,  no  fever. 

Status  praesens:  Polyps  in  the  canal,  marked  discharge. 
Mastoid  not  sensitive.  Total  facial  paralysis  1.  Temp.  37.8. 
E.e. :  Normal. 

Functional  test:  L.e. :  Tested  with  exclusion  apparatus, 
perceives  only  loud  shouting  and  the  tones  of  the  harmonica 
without  differentiating  them.  W.  in  head,  R.  — ,  Sch.  short- 
ened. Spont.  ny.  (behind  glasses)  to  r.  No  ny.  on  mov- 
ing head.  No  fistula  sympt.  Cal.  react,  not  present.  Tr.  r. 
=  ny.  horiz.  1.  8" ;  tr.  1.  =  ny.  horiz.  r.  16". 

Operation,  Mry  1:  A  large  sequestrum  is  felt  in  the 
tympanic  cavity,  which  is  removed  after  widening  the 
passage.  This  sequestrum  is  embedded  in  granulations.  It 
contains  the  inferior  wall  of  the  external  auditory  canal, 
the  inner  half  of  the  fossa  of  the  mandibular  joint,  as  well 
as  the  facial  canal,  with  the  central  portion  of  the  nerve 
lying  free.  The  sinus  and  the  posterior  fossa  are  laid  bare. 
The  horizontal  semicircular  canal  and  the  labyrinth  are 
opened  up  to  the  internal  auditory  meatus.    Through  a  tear 


194  DISEASES  OF  THE  LABYRINTH 

in  the  dura  of  the  posterior  fossa,  a  small  amount  of  fluid 
escapes.  Pus  comes  from  the  labyrinth.  An  iodoform  wick 
is  placed  in  the  tear  in  the  dura,  another  in  the  cavity  left 
by  the  sequestrum.    Plastic,  packing,  dressing. 

May  1 :  Temp.  37.3. 

May  2:  Feels  well.     Temp.  38.6. 

May  3:  Some  headache.  Large  flow  of  liquid  from  the 
wound.    Temp.  39.0.    Dressing. 

May  4:  Somnolent.     Coma.     Death. 

Postmortem  (Docent  Battel) :  Purulent  meningitis  of  the 
base  and  convexity  of  the  brain.  Pachymeningitis  pu»u- 
lenta  interna  of  the  1.  posterior  fossa.  Healed  apex  tuber- 
culosis.   Fatty  degeneration  of  internal  organs. 

75.  J.  A.  Age  4.  Admitted  May  1,  1908. 

Anamnesis :  Otitis  after  scarlet  fever. 

Status  praesens:  R.e. :  Normal.  L.e. :  Fistula  in  the  mas- 
toid, marked  purulent  discharge  from  the  meatus,  which  is 
filled  with  polyps.    Temp.  37.1. 

Functional  test:  Deaf  for  speech  and  tuning  forks.  Xo 
spont.  ny.,  no  fistula  sympt.  Cal.  react,  negative.  Turning 
•reaction,  after  tr.  r.,  weak  ( ?) ;  after  tr.  1.,  strong. 

Operation^  May  2  {Bardny) :  Radical.  Large  sequestnim 
embracing  a  part  of  the  tegmen  and  the  mastoid.  Dura  of 
the  middle  and  posterior  fossae  lie  exposed;  likewise  the 
sinus,  which  is  covered  with  granulations.  Posterior  meatal 
wall  destroyed.  In  the  labyrinth  (in  the  region  of  the  am- 
pulla of  the  anterior  vertical  semicircular  canal),  a  large, 
round  fistula,  out  of  which  appear  polyps.  The  horizontal 
canal  is  entirely  destroyed,  appearing  as  a  gi'oove.  Laby- 
rinth operation,  without  exposure  of  the  posterior  fossa. 
Vestibule  opened  from  behind.  Promontory  opened.  Fis- 
tulae  of  the  ampulla  and  vestibule  enlarged,  a  small  bony 
support  left  on  the  other  side.  Plastic.  Facial  intact  after 
the  operation. 

May  3 :  Ny.  rotat.  1.    Temp.  38.2. 

May  4:  No  ny.    Feels  well ;  38.5. 


CASE  HISTORIES  195 

May  5 :  Normal  tempt,  from  this  date. 
May  7:  First  change  of  dressing.    AVound  looks  well. 
May  20:  Dressing  until  now  every  other  day.     "Wound 
filled  with  healthy  granulations.    Discharged,  cured, 

76.    H.  U.    Age  22.    Female.    Admitted  May  25,  1908. 

Anamnesis:  R.e. :  Diseased  for  years.  Recently  no  dis- 
charge. Up  to  eight  days  ago,  patient  complained  of  tran- 
sient headaches.  During  the  past  eight  days  the  pains  have 
increased;  fever,  vomiting  vertigo.  Fourteen  days  ago, 
some  discharge,  bad-smelling  pus,  after  which  she  felt  some 
better.  During  past  two  days,  stiffness  of  neck.  Pier 
consciousness  undisturbed.  The  pains  are  localized  in  the 
r.  parietal  and  occipital  regions.  Hearing  on  r.  side  has 
always  been  poor.  Two  normal  confinements;  now  two 
months  pregnant.  Husband  says  he  knows  of  no  other  sick- 
ness and  himself  denies  lues. 

Status  praesens:  Patient  admitted  in  very  bad  condition 
at  11  A.M.  Temp.  37.7.  Pulse  78  (high  tension,  rythmic). 
Of  medium  size;  poorly  nourished;  anaemic.  Lies  bent  on 
her  left  side.  Raising  her  causes  great  distress,  and  can 
be  done  only  passively.  Then  she  holds  her  head  turned  to 
the  1.  and  backward.  If  held  rigidly,  turning  head  to  the 
median  position  is  very  painful.  Patient  responds  when 
addressed,  but  lies  with  eyes  closed.  No  stupor  or  delirium. 
Complains  of  pains  in  the  occipital  region  and  neck.  R.e. : 
Deaf  for  speech  and  tuning  forks.    Fistula  sympt.  negative. 

On  sitting  up  and  lying  down  again,  very  marked,  large 
vertical  ny.  was  produced.  Unable  to  produce  it  again. 
Variable,  small  horiz.  ny.  when  eyes  are  in  extreme  abduc- 
tion. Abducens  paralysis.  Facial  intact.  Further  exami- 
nation postponed  until  consultation  with  internist  and 
ophthalmologist,  for  patient  asks  for  a  rest.  Operation  ar- 
ranged for  afternoon.  1.45  P.M.:  Patient  shows  excite- 
ment, with  violence.    Then  becomes  quiet  and  dies. 

Postmortem  report,  May  26,  8  P.  M.  (Prof.  Ghon) :  Dif- 
fuse, purulent,  fetid,  meningitis,  most  marked  in  the  large 


196  DISEASES  OF  THE  LABYRINTH 

lymph  space  at  the  base  of  the  brain.  A  fetid  abscess,  the 
size  of  a  nut,  with  perforation  in  the  inferior  cornn, 
pyocephalus  with  pseudomeUmosis  of  the  ependyma ;  cir- 
cumscribed internal  and  external  pachymeningitis  over  the 
r.  antrum;  chr.  otitis  media  r.  with  cholesteatoma  in  the 
antrum.  In  the  exudate  of  the  meningitis,  abundant  bac- 
teria, chiefly  Gram-positive,  of  various  forms. 

77.    N.  R.    Age  3.    Admitted  June  24, 1908. 

Anamnesis:  Scarlet  fever  eighteen  months  ago,  after 
which,  discharge  r.  As  the  condition  did  not  improve,  pa- 
tient was  operated  one  year  ago,  but  the  discharge  has  con- 
tinued. For  past  six  months.  I.e.  has  also  discharged.  The 
father  says  the  child  is  entirely  deaf.  No  vertigo,  headache 
or  emesis. 

Status  praesens:  R.e. :  A  cavity,  the  size  of  a  cherry,  in 
the  mastoid,  with  margins  of  bluish-red  necrotic  skin;  and 
in  the  deeper  parts  of  the  cavity,  fragments  of  necrosed 
bone.  Abundant  yellowish-green,  thick,  creamy  pus.  Up- 
per and  posterior  walls  of  canal  greatly  depressed.  Granu- 
lations and  cholesteatomatous  masses  deep  in  the  canal. 
L.e. :  Small  fistula  behind  the  ear,  discharging  fetid  yellow 
pus. 

Functional  test:  Child  is  too  young  for  a  reliable  test, 
but  it  certainly  cannot  hear  with  r.  ear.  Perceives  a  fork 
held  near  I.e.  Spont.  ny.  at  most  is  very  slight.  Turning 
ny. :  I.e.  =  0 ;  r.e.  =  trace.    Cal.  react,  r.  =  0, 1.  +. 

Operation  r.e.,  June  29  (Ruttin) :  Incision  near  retro- 
auricular  fistula.  Periosteum  pushed  aside,  exposing  a  cav- 
ity filled  with  necrotic  bone  fragments  and  sequestra,  dis- 
colored black.  The  sequestra,  which  reach  to  the  dura  of 
the  middle  and  posterior  fossae,  are  removed.  Dura  of  the 
middle  and  posterior  fossae  and  the  sinus  are  laid  bare  over 
a  large  area.  They  are  discolored  a  yellowish-red  and  cov- 
ered with  granulations.  Typical  radical  operation.  A  fis- 
tula is  now  seen  in  the  horizontal  canal.  Typical  labyrinth 
operation,  under  difficulties  presented  by  the  smallness  of 


CASE  HISTORIES  197 

the  field  and  by  bleeding  from  a  branch  of  the  styloid  artery. 
Labyrinth  opened  from  behind.  Facial  nerve  lies  exposed 
in  the  tympanic  cavity.    Panse's  plastic.    Dressing. 

July  4:  Dressing.  Wound  normal.  Operation  on  left 
side:  Typical  radical  operation.  Dura  not  exposed. 
Panse's  plastic. 

Aug.  7 :  No  spont.  ny.    No  ny.  after  turning. 

Sept.  9 :  Transferred  to  O.P.  Dept. 

78.  L.  M.   Age  44.   Male.  Admitted  July  18,  1908. 

Anamnesis:  Seven  weeks  ago,  noticed  that  his  face  was 
distorted,  felt  pains  in  the  I.e. ;  at  the  same  time,  became 
dizzy  and  had  a  fever,  so  that  hQ  took  to  his  bed.  A  physi- 
cian gave  him  electricity  every  other  day.  There  was  then 
no  discharge.  Three  weeks  ago  the  discharge  began,  and  he 
was  sent  to  the  clinic. 

Status  praesens:  External  canal  wide;  a  large  polyp 
growing  from  the  antrum  covers  a  part  of  the  drum- 
head. The  rest  of  the  drumhead  is  reddened  and  covered 
with  pus.  Perforation  is  not  visible.  Cholesteatoma.  R.e. : 
Normal. 

Functional  test:  L.e.  (tested  with  exclusion  apparatus): 
Con.v.  40  cm.;  whisp.  10  cm.;  Sch.  shortened;  c^  poorly 
heard.  Cal.  react,  negative.  Had  vertigo  before.  No 
spont.  ny. 

Operation  {Ernst  Urbantschitsch) :  On  opening  the  an- 
trum, there  appear  masses  of  cholesteatoma,  which  reach 
to  the  dura  of  the  middle  fossa,  which  lies  exposed  over  a 
considerable  area.  The  facial  ridge  has  been  entirely  de- 
stroyed by  cholesteatoma.  In  the  anterior  end  of  the  hori- 
zontal canal  there  is  a  wide  fistula,  in  ivhich  it  is  possible 
to  pass  an  ordinary  probe.  Ossicles  gone.  Dura  of  the 
posterior  fossa  and  the  sinus  not  exposed.    Panse's  plastic. 

July  21 :  Some  pain  in  the  wound,  no  fever,  no  ny. 

July  22-25,  A.M.:  Feels  well,  no  temp.  P.M.:  Temp. 
40.  Therefore,  dressings  are  changed.  Wound  looks  very 
well.    No  free  pus.    Light  packing.    Compresses. 


J98  DISEASES  OF  THE  LABYBIMH 

July  26 :  Dressing.  Wound  normal.  No  free  pus.  Some 
headache.    Speech  not  entirely  coherent.    Slight  stupor. 

July  28,  7  A.M. :  Temp.  37.4.    Stupor.    Delusions. 

July  29 :  Unconscious.    11  A.M. :  Death. 

Postmortem:  Decomposed,  fatty  deposit  on  the  inner 
surface  of  the  dura  in  the  vicinity  of  the  operative  field,  and 
diffuse,  dirty,  greenish-brown  discoloration  of  the  surround- 
ing parts  of  the  dura.  Decomposed  abscess  in  the  left  pa- 
rietal lobe,  as  well  as  of  the  parts  reaching  toward  the  ver- 
tex, etc.,  etc. 

79.  E.  K.  Female.  Age  Si/o  years.  Admitted  Aug. 
26,  1908. 

Anamnesis:  Had  scarlet  fever  thirteen  weeks  ago. 
Measles  three  weeks  later.  In  the  fourth  week,  a  severe 
sore  throat  and  discharge  from  both  ears. 

Status  praesens:  R.e. :  Canal  narrowed,  filled  with  granu- 
lations. Suppuration.  Skin  over  the  mastoid  oedematous. 
Deaf.  Cal.  react.  — .  L.e. :  Drumhead  bulging,  perforation 
in  the  anterior  inferior  quadrant.    Suppuration. 

Operation  (Ruttin) :  Large  fistula  in  mastoid,  filled  with 
granulations  and  sequestra,  and  including  a  part  of  the 
posterior  wall  of  the  external  auditory  canal.  Mastoid 
opened  and  three  sequestra,  the  size  of  a  bean,  removed. 
Radical  operation.  Antrum  cleaned  of  granulations.  An- 
trum is  enlarged ;  its  walls  all  softened.  Now  is  seen  a  dis- 
colored fistula,  several  mm.  in  diameter,  in  the  horizontal 
canal.  Besides  this,  a  fistulous  tract  leads  into  the  laby- 
rinthine nucleus.  This  is  curetted.  The  softening  extends 
to  the  tegmen,  which  is  in  part  removed,  so  that  the  dura, 
covered  with  granulations,  lies  exposed  for  an  area  equal 
in  size  to  a  bean.  In  curetting  the  tympanic  cavity,  we 
see  that  the  posterior  meatal  wall  is  largely  destroyed. 
Plastic  after  Neumann.  Iodoform  wick.  Dressing.  On  the 
day  after  the  operation,  very  slight  rotat.  ny.  to  the  op- 
posite side,  without  any  vertigo.  No  preference  for  any 
particular  posture  in  bed.    During  the  next  two  days  the 


CASE  niSTORlES  199 

slight  ny.  entirely  disappears.  First  change  of  dressing 
shows  moderate  discharge.  Ketro-auricular  transverse  in- 
cision.   Stitch  abscess.    Feels  well. 

Sept.  7 :  Dressing.  Some  pus  from  behind.  Removal  of 
a  packing  which  was  overlooked. 

Sept.  9 :   Transferred  to  O.P.  Dept. 

80.  E.  B.  Female.  Age  23.  Admitted  Sept.  25,  1908. 

Anamnesis :  Discharge  from  both  ears  for  nineteen  years, 
following  measles.  Then  was  deaf  on  both  sides,  according 
to  her  statement.  L.e.  improved,  while  the  hearing  with 
the  r.e.  has  always  remained  very  poor.  The  discharge  con- 
tinued with  transient  remissions  until  now.  Occasional 
pains  in  the  r.  parietal  region.    No  vertigo,  no  emesis. 

Status  praesens:  R.e.:  Drumhead  totally  destroyed.  De- 
posit of  pus  on  mucous  membrane  of  tympanic  cavity.  L.e. : 
Drumhead  nearly  destroyed.  Round  window  visible.  Tym- 
panic cavity  granulating. 

Functional  test:  R.e.:  Tested  with  exclusion  apparatus, 
deaf  for  speech  and  tuning  forks.  R.  — ,  Sch.  shortened, 
no  fistula  sympt.  Cal.  react,  negative.  L.e. :  Con.v.  41/2  m., 
whisp.  1  m.  W.  1.,  R.  — ,  Sch.  shortened;  Ci  and  c^  short- 
ened; no  fistula  sympt.  Cal.  react.  +.  After  tr.  r.,  ny. 
horiz.  1.  25"  (repeated,  15").  After  tr.  1.,  ny.  horiz.  r.  =  12" 
(repeated,  16").  No  tinnitus  or  vertigo.  Spont.  ny.  slight 
to  both  sides. 

Operation,  Oct.  5  (Ernst  U  rh  ants  chits  ch) :  Carious  an- 
trum opened.  Dura  of  the  middle  fossa  laid  bare  over  an 
area  the  size  of  a  small  lentil.  At  the  lower  angle  of  the 
facial  ridge  is  a  carious  area  covered  with  granulations. 
This  is  removed.  In  the  carious  tympanic  cavity  only  cari- 
ous anvil  is  found.  The  labyrinth  probe  does  not  enter 
the  labyrinth,  nor  does  the  labyrinth  capsule  present  patho- 
logical changes.  The  horizontal  semicircular  canal  is 
opened,  and  the. promontory  wall  removed.  Nothing  un- 
usual in  the  labyrinth.     Panse's  plastic  without  sutures. 


200  DISEASES  OF  THE  LABYRINTH 

Iodoform  wiek  packing.  During  the  operation,  slight 
twitching  of  the  face  muscles. 

Oct.  6 :  No  ny.,  no  headache.  7.30  A.]\I. :  Slight  spont.  ny. 
r.    9  A.M. :  Slight  spont.  ny.  1. 

Oct.  7 :  No  vertigo,  headache  or  ny. 

Oct.  8  and  9 :  Feels  well. 

Oct.  10:  Dressing  changed.  Healing  excellent.  No  pus. 
No  ny.  on  pressing  on  the  horizontal  canal,  or  on  irrigating 
with  cold  saline.    Light  iodoform  packing. 

Oct.  11-15 :  No  ny.    Normal  progress. 

Oct.  16:  Dressing.    Discharged. 

81.  H.  F.  Age  9.  Admitted  Sept.  25,  1908. 

Anamnesis:  Chr.  suppuration  both  ears,  healed  on  1.  side, 
present  on  r.  Fell  upon  head  six  weeks  ago.  Brought  to 
the  clinic  because  of  emesis,  fever  and  headache. 

Status  praesens:  L.e. :  Dry  perforation.  Membrane  to- 
tally destroyed.  Promontory  covered  with  epithelium. 
E.e. :  Perforation  below  the  hammer.  Slight  discharge. 
Mastoid  not  sensitive.  Slight  stiffness  of  neck.  Variable 
headache,  especially  over  the  forehead.  Nasal  cavity  nega- 
tive. HypertrojDhied  tonsils.  Keflexes  normal.  No  ataxia. 
Pulse  small.  Somewhat  irregular  respiration.  Splenic  en- 
largement. 

Functional  test:  Tested  with  exclusion  apparatus,  deaf 
for  speech  and  tuning  forks.  No  fistula  sympt.  Cal.  react, 
and  turning  react,  not  demonstrable.  Spont.  ny.  r.  (mod- 
erate). No  vertigo.  L.e.:  Hearing  and  caloric  react,  nor- 
mal. Repeated  emesis.  Beautiful  example  of  domed  skull 
{Turmschddel) . 

Operation:  The  first  blow  of  the  chisel  exposes  the  sinus 
pulsating  in  the  wound.  A  small  amount  of  pus  and  granu- 
lation tissue  in  the  antrum.  Radical  operation.  Facial 
ridge  smoothed  without  facial  twitching.  Prominence  of 
the  horizontal  semicircular  canal  intact.  Oval  window  filled 
"wdth  granulations.  Stapes  cannot  be  found.  Labyrinth 
opened  from  the  promontory  and  the  ampulla  of  the  hori- 


CASE  HISTORIES  201 

zontal  and  anterior  vertical  canals.  In  cleaning  the  hypo- 
tympanic  cavity,  some  hleeding.  In  exposing  the  floor  of 
the  tympanic  cavity,  the  pulsating  jugular  bulb  appears. 
Plastic  after  Panse.  Dressing.  No  flow  of  lymph.  Lum- 
bar puncture.  Low  pressure.  Turbid  cerebrospinal  fluid. 
After  the  operation,  the  patient  does  not  complain  of  pains. 
No  ny.    At  2  A.M.,  sudden  death. 

Postmortem  (Dr.  Wiesne)-) :  Purulent  meningitis  of  the 
base  of  the  cerebrum  and  cerebellum;  abundant  exudate, 
acute  oedema  of  the  brain.  Multiple  old  hemorrhages 
over  the  convex  surface  of  the  cerebrum  (''plaque  jaune") 
after  trauma  of  the  skull.  Eadical  and  labyrinth  operation 
of  r.  ear  for  chronic  otitis  and  labyrinth  suppuration,  etc., 
etc.    Bacteriological  findings:  Streptococci. 

82.  M.  M.  Age  60.  Male.  Admitted  Jan.  14,  1909. 

Anamnesis:  Since  Dec,  1908,  has  had  trouble  with  r.e., 
following  an  influenza.  Four  days  later,  discharge,  which 
has  continued.  Right  side  of  patient  is  painful,  especially 
at  night.    No  vertigo  at  present,  no  tinnitus. 

Status  praesens:  L.e. :  Normal.  R.e.:  Total  destruction, 
polyps. 

Functional  test:  Con.v.  I14  m.  Whisp.  %  m.  With  ex- 
clusion apparatus  to  1.  ear,  total  deafness.  W.  r.,  R.  — , 
Sch.  shortened;  C  0,  Ci  0;  c^  0.  Some  spont.  ny.  rotat.  1. 
A  trace  of  rotat.  ny.  1.  behind  opaque  glasses.  No  fistula 
sympt.  Cal.  react,  not  demonstrable  (3  irrigations  with 
cold  water). 

Operation,  Jan.  16  (Bondy) :  Bone  sclerotic.  Antrum 
large,  and  filled  with  pus  and  cholesteatomatous  material. 
Typical  radical  operation.  Foramen  ovale  empty.  Hori- 
zontal canal  has  a  large  fistula,  and  probe  presses  out  gran- 
ulations and  pus.  The  bridge  between  the  fistula  and  the 
foramen  ovale  is  about  1  mm.  in  thickness.  Typical  laby- 
rinth operation,  with  exposure  of  the  dura  of  l)oth  fossae. 
On  cleaning  out  the  cochlea,  a  large  polyp  comes  out  of  the 


202  DISEASES  OF  THE  LABYRINTH 

fistula  in  the  horizontal  canal.  Total  facial  paralysis  after 
the  operation. 

Jan.  17:  Slight  ny.  on  looking  toward  the  healthy  side. 
No  vertigo.    Evening :  Temp.  38.0.    Dressing  changed. 

Feb.  24 :   Partially  covered  with  epidermis.    Discharged. 

83.  J.  K.  Age  29.  Admitted  Jan.  26,  1909. 

Anamnesis:  Discharge  from  I.e.  since  childhood;  from  r. 
ear  for  four  or  five  years.  In  Nov.,  1909,  severe  attacks  of 
vertigo.  Severe  pain  in  the  I.e.,  so  that  the  patient  lay  in 
bed  four  weeks.  Gradually  the  vertigo  decreased,  but  re- 
curs on  bending  or  running.  Still  has  headache,  more  on 
1.  side.    Temp.  37.2. 

Status  praesens:  R.e. :  Drumhead  largely  destroyed,  two 
granulations  from  above.  On  the  promontory,  dried  se- 
cretion and  particles  of  epidermis.  L.e. :  Large  polyp,  fill- 
ing meatus.  Dried  secretion.  Drumhead  not  visible. 
Polyp  comes  apparently  from  attic. 

Functional  test:  R.e.:  Con.v.  5-6  m.  Whisp.  1  m.  W.  r., 
R.  — ,  Sch.  lengthened.  Ci  -f,  c^  +.  Spont.  ny.  r.  No  fis- 
tula sympt.  Caloric  react,  prompt.  L.e. :  Tested  with  ex- 
clusion apparatus,  deaf  for  speech  and  tuning  forks.  No 
fistula  sympt.  Cal.  react.  0.  After  tr.  1.,  ny.  horiz.  r.  21". 
After  tr.  r.,  ny.  horiz.  1.  12".    No  spont.  ny. 

Operation,  Jan.  29  (Bdrdny) :  Radical  operation.  A 
large  fistula  in  the  horizontal  semicircular  canal,  through 
which  granulations  can  be  removed  from  the  labyrinth. 
Labyrinth  operation.  Posterior  fossa  laid  bare.  The  hori- 
zontal canal  is  removed,  exposing  the  facial  nerve.  Base 
of  the  petrosal  bone  removed.  Promontory  opened.  Laby- 
rinth filled  with  granulations.  No  flow  of  cerebrospinal 
fluid.  Temp.  37.3;  Jan.  30,  37.6;  Jan.  31,  37.2;  Feb.  1,  37.1 
to  38.0. 

Feb.  2:  37.4  to  38.0. 

Feb.  13 :  Occasional  fever.    Discharge  less. 

Feb.  14:  Dismissed  to  O.P.  Dept. 


CASE  HISTORIES  203: 

84.   E.  P.  Female.  Admitted  Feb.  3,  1909. 

Anamnesis:  Disease  of  r.e.  for  thirty-two  years,  during 
whicli  time  there  lias  been  discharge,  except  at  short  in- 
tervals. Occasional  treatment.  Has  frequent  headaches. 
For  one  week,  very  severe  headache  on  r.  side,  extending 
into  occipital  region ;  evening,  vomiting;  at  first,  food ;  later, 
mucus.  The  next  day  she  noticed  a  swelling  over  the 
zygoma  and  the  upper  half  of  the  nose.  At  the  same  time 
she  had  severe  pains  in  this  region.  The  swelling  subsided, 
but  the  pain  remained. 

Status  praesens:  L.e. :  Normal.  R.e.:  Large  perforation 
in  the  anterior  superior  quadrant;  within  the  perforation, 
abundant  masses  of  epithelium  (cholesteatoma?).  Small 
perforation  in  the  posterior  superior  quadrant  behind  the 
hammer.    Slight  fetid  discharge.    Temp,  normal. 

Functional  test:  R.e.:  Deaf  for  speech  and  tuning  forks 
(tested  with  exclusion  apparatus).  W.  in  head,  R.  oo  — , 
Sch.  shortened ;  slight  spont.  ny.  rotat.  to  1.  Cal.  react,  not 
demonstrable.  Fistula  sympt.  0.  After  tr.  r.,  ny.  horiz.  1. 
15" ;  after  tr.  1.,  ny.  horiz.  r.  10". 

Operation,  Feb.  5  {Ernst  Urbantschitsch) :  Radical  op- 
eration. Bone  sclerotic,  antrum  small.  Facial  ridge  very 
prominent,  horizontal  semicircular  canal  intact.  Granula- 
tions in  the  hypotympanic  cavity.  Dura  of  the  middle  and 
jjosterior  fossae,  and  also  the  sinus,  laid  bare.  Vestibule 
opened.  The  labyrinth  probe  enters  the  middle  ear  in  front 
of  the  posterior  surface  of  the  pyramidal  bone.  Cerebro- 
spinal fluid  flows  awaj'.  Dura  of  the  posterior  surface  of 
the  pyramid  adherent  to  the  bone.  After  the  operation,  the 
facial  is  intact.  Some  pain  in  the  wound,  frequent  emesis 
during  the  night. 

Feb.  5 :  Evening.    Facial  intact,  no  ny.,  temp.  37.4. 

Feb.  6:  Some  pain  in  wound,  and  headache;  facial  in- 
tact, no  ny.,  temp.  37.8. 

Feb.  7 :  Relatively  well  and  looks  well.  Has  a  good  ap- 
petite, no  fever,  temp.  37.2. 

Feb.  8:  Headache  during  the  night.    Very  pale  and  ex- 


204  DISEASES  OF  THE  LABYRINTH 

tremely  weak,  unable  to  take  liquids  without  help.  A.M.: 
Vomited  once.  Very  irritable ;  easily  frightened.  Hysteri- 
cal.   Suspicious. 

Feb.  9:  Temp.  37.8. 

Feb.  10:  Feels  better.  Headache  less.  Appetite  better. 
Sleeps  poorly.    Temp.  37.8. 

Feb.  11 :  Subjectively  better.  Has  dressing  while  sitting 
up.  Wound  doing  well.  Posterior  to  the  facial  prominence 
and  horizontal  semicircular  canal,  it  is  entirely  dry.  In  the 
labyrinth  a  single  drop  of  pus.  Light  packing.  Dressing. 
Temp.  36.8  to  37.4. 

Feb.  15 :  Feels  well.  Out  of  bed  once.  Temp,  to  Feb.  15, 
between  37.2  and  38.0. 

Feb.  16:  Some  headache,  otherwise  well.  Dressing. 
"Wound  healing  well.  Slight  deposits  on  the  dura.  Little 
discharge.    Temp.  37.4. 

Feb.  17 :  Feels  well.  Dressing.  Temp,  normal  from  now 
on. 

Feb.  19 :  Dressing.    Transferred  to  O.P.  Dept. 

85.  T.  K.   Age  3.  Admitted  June  14,  1909. 

Anamnesis:  Nine  weeks  ago,  measles.  Until  then,  well, 
though  child  has  complained  of  pain  in  1.  e.  when  washed 
during  past  six  months.  Discharge  was  not  noticed.  L.e. 
began  to  discharge  while  in  the  hospital  with  measles. 
Scarlet  fever  followed  measles,  when  r.  ear  began  to  dis- 
charge. Nephritis.  Discharged  from  Franz-Joseph  Hospi- 
tal fourteen  days  ago. 

Status  praesens:  Large  perforation.  Fetid  secretion. 
L.e. :  Large  perforation  in  anterior  inferior  quadrant.  Fis- 
tula behind  the  ear. 

Functional  test:  Hearing  test  impossible.  Cal.  ny.  r.  +, 
1.  0.  No  spont.  ny.,  no  fistula  sympt.,  no  fever.  Eczematous 
conjunctivitis. 

Operation,  June  15  (Bondy) :  Sequestrum  of  part  of  mas- 
toid surface  the  size  of  a  heller  piece.  Radical  operation. 
A  round  fistula  in  the  horizontal  canal,  through  which  the 


CASE  HISTORIES  205 

probe  is  easily  passed.  Dura  of  posterior  fossa  laid  bare 
and  the  semicircular  canal  opened  from  behind.  Vestibule 
not  opened.  Granulations  in  the  horizontal  canal.  Cochlea 
cleaned  out.  P.M.:  Patient  has  not  vomited  and  is  veiy 
bright.  Temp,  normal.  Slight  ny.  rotat.  r.  No  fever. 
July  11 :   Transferred  to  O.P.  Dept. 

86.  Th.  S.  Female.  Age  13.  Admitted  Aug.  28,  1909. 

Anamnesis :  In  May,  patient  noticed  an  abscess  back  of 
the  ear  which  had  discharged  since  Jan.  Abscess  opened 
spontaneously.    Had  headache ;  no  emesis. 

Status  praesens:  L.e. :  Noraial.  R.e. :  Drumhead  red, 
covered  with  fetid,  greasy  pus.»  Retro-auricular  swelling 
with  elevated  fistulous  opening.  Facial  paralysis  for  five 
weeks. 

Functional  test:  With  exclusion  apparatus,  deaf  for 
speech  and  tuning  forks.  W.  1.,  R.  — ,  Sch.  shortened;  no 
spont.  ny.,  no  fistula  symptom.  Cal.  react,  not  demonstra- 
ble (possibly  the  slightest  trace).  After  tr.  1.,  horiz.  ny.  r. 
5  movements  in  10" ;  after  tr.  r.,  ny.  horiz.  1.,  36  movements 
in  26". 

Operation  (Ruttin) :  Sclerotic  mastoid  opened.  Sinus 
lies  well  forward ;  normal.  Typical  radical  operation.  Pin- 
head  fistula  in  horizontal  canal.  Inner  wall  of  tympanic 
cavity  covered  with  diffuse  granulations  which  fill  the 
cochlea.  Probe  enters  the  oval  window  freely.  Vestibulum 
opened  from  behind.  Probe  passed  back  of  the  facial  into 
tympanic  cavity.  The  probe  encounters  a  loose  fragment 
of  bone  in  the  depths  of  the  labyrinth,  which,  on  being  re- 
moved, proves  to  be  a  part  of  the  lower  turn  of  the  cochlea. 
Dura  of  posterior  fossa  laid  bare  and  the  vestibulum  opened 
from  behind.  Curettage.  Dressing.  Temp.  37.9.  Sept.  5, 
36.9  to  38.4;  Sept.  6,  36.5  to  37.8;  Sept.  7,  36.7  to  37.7. 

To  Sept.  8:  Xy.  rotat.  1.,  not  very  large.  No  vertigo. 
Temp,  from  now  on  normal. 

Sept.  10:  First  change  of  dressing.  Wound  healthy; 
slight  discharge.    Packing  removed. 

Sept.  16:  Transferred  to  O.P.  Dept. 


206  DISEASES  OF  THE  LABYRIXTH 

87.   M.  R.   Female.   Age  21.   Admitted  May  14,  1909. 

Anamnesis :  In  Feb.,  1908,  had  pains  in  I.e.,  followed  by 
discharge,  lasting  until  summer.  After  conservative  treat- 
ment the  discharge  ceased,  returning  in  the  "winter.  Re- 
newed discharge  since  Feb.,  continuing  until  now.  In  the 
beginning  of  this  attack,  vertigo  for  two  days,  and  tinnitus 
until  now.    No  emesis,  much  headache. 

Status  praesens:  L.e. :  Mucous  membrane  of  tympanic 
cavity  granulating.  Fetid  discharge.  Deaf  for  speech  and 
tuning  forks.  Fistula  sympt.  — .  Cal.  react.  0.  Temp. 
37.6.    R.e. :  Drumhead  retracted.    Calcifications. 

Operation  (Ruttin) :  Cholesteatoma  in  antrum,  which  has 
destroyed  its  lateral  wall  ^d  has  invaded  the  meatus.  Typ- 
ical radical  operation.  Region  of  the  oval  window  is  cov- 
ered with  a  granulation.  Probe  enters  without  resistance 
through  the  oval  window.  Typical  labyrinth  operation, 
with  exposure  of  the  dura  of  the  posterior  fossa.  Probe 
passed  behind  the  facial  appears  in  the  posterior  fossa.  No 
flow  of  the  cerebrospinal  fluid.  Promontory  removed.  Fa- 
cial intact. 

May  18:  Severe  ny.  rotat.  r.  Vertigo,  emesis;  lies  on  r. 
side.    Temp.  37.8.    Pulse  80. 

May  19:  Ny.,  vertigo,  vomiting  like  yesterday,  nausea, 
headache,  pain  in  wound.    Temp.  37.2,  pulse  80. 

May  20:  Headache  less,  ny.  rotat.  r.  somewhat  less. 
Nausea  and  vertigo.  Pain  in  wound.  Lies  mostly  on  r. 
side,  but  sometimes  upon  back.    Temp.  37.6.    Pulse  92. 

May  21 :  Condition  decidedly  better.  Ny  rotat.  r.  much  less. 
No  nausea,  slight  vertigo.  Pain  in  head  and  in  the  wound. 
Lies  upon  back.  Evening:  Sudden  nausea  and  vomiting. 
I  examined  patient  about  half  an  hour  after  the  onset  of 
this  attack  during  the  nausea  and  vomiting,  but  could  make 
out  no  essential  change  in  the  existing  ny.  Temp.  36.6. 
Pulse  72. 

May  22:  Feels  well.  Ny.  rotat.  r.  very  slight.  Some 
headache  and  pain  in  the  ear.  P.M.:  Complains  of  sudden 
nausea  and  severe  vertigo;  severe  attack  of  ny.  rotat.  r. 


CASE  HISTOh'IES  207 

This  ny.  uncliangetl  b}^  sitting  up.  Feels  well  again  after 
one-half  hour.    Temp.  37.6.    Pulse  72. 

May  23 :  Feels  well,  except  for  headache  and  pain  in  ear. 
Ny.  rotat.  r.  slight,  xlppetite  good.  First  change  of  dress- 
ing. Abundant  discharge,  not  fetid.  Dura  looks  well.  No 
cerebrospinal  fluid.    Temp.  37.4.    Pulse  84. 

May  24:  Noticeably  well.  No  headache,  no  pain  in  the 
ear.  Lies  upon  back,  for  the  first  time,  without  cold  com- 
press to  forehead,  ^''ertigo  on  sitting  up,  but  less.  Temp, 
normal.  No  more  vertigo.  Ny.  rotat.  r.,  slight  and  small 
in  movement.  Wound  shows  normal  course.  Occasional 
tinnitus  in  operated  ear. 

June  30 :  Transferred  to  O.P.  Dept.,  with  wound  nearly 
healed. 

88.  H.  St.  Age  4.  Admitted  Sept.  20, 1909. 

Anamnesis :  At  age  of  one  year,  discharge  from  1.  ear. 
Since  then,  occasional  discharge.  Increased  discharge  dur- 
ing past  fourteen  days.  Since  yesterday,  mother  noticed  a 
swelling  behind  the  ear. 

Status  praesens:  Fluctuating  swelling  behind  1.  ear. 
Fetid  pus  and  cholesteatoma  in  the  canal.  Granulations 
deep  in  canal. 

Functional  test:  Hearing  test  impossible.  Cal.  test.  1,  0. 
Turning  ny.  r.,  prompt;  1.,  practically  0.  No  fistula  reac- 
tion. No  spont.  ny.  Slight  facial  paresis  recognized  by 
slow  closing  of  eyelid  when  head  is  bent  backward. 

Operation,  Sept.  21  (Ruttin) :  Fistula,  the  size  of  a  pea, 
in  the  cortex.  Extensive  destruction  of  the  mastoid,  which 
is  filled  with  pus  and  granulations.  The  diseased  bone  ex- 
tends to  the  dura  of  the  middle  and  posterior  fossae  and  to 
the  sinus,  all  of  which  lie  in  part  exposed  and  are  covered 
with  granulations.  Before  healthy  tissue  is  reached,  the 
jugular  bulb  is  exposed  and  laid  bare  according  to  the 
method  of  Voss.  The  bulb  appears  to  be  normal.  Healthy 
dura  over  the  cerebellum  is  first  encountered,  below,  near 
the  cranial  base ;  posteriorly,  behind  the  sinus ;  above,  over 


208  DISEASES  OF  THE  LABYRINTH 

the  bend  of  the  sinus,  and  forward,  cannot  be  found  before 
proceeding  with  the  Labyrinth  operation.  Typical  labyrinth 
operation.  Dura  of  the  middle  fossa  is  laid  bare  over  an 
area  the  size  of  a  gulden  before  healthy  tissue  is  reached. 
Angle  of  the  pyramid  is  removed  as  far  as  the  labyrinth 
nucleus.    Plastic. 

Sept.  22 :  The  child  is  noticeably  quiet.  No  ny.,  no  ver- 
tigo. Lies  upon  r.  side.  No  emesis.  Complains  only  of 
headache.    Restless  sleep.    Temp.  37.2. 

Sept.  23:  No  ny.,  no  vertigo.  Slept  quietly.  Pulse  92. 
Temp.  37.4. 

Normal  course.  Discharged,  with  granulating  wound, 
Oct.  21. 

89.   B.  M.  Female.  Age  50.  Admitted  Sept.  28,  1909. 

Anamnesis:  Chr.  discharge.  For  ten  days,  severe  pains 
in  ear,  with  vertigo  and  vomiting.  No  fever.  At  the  same 
time  patient  noticed  that  her  face  was  "crooked."  Stum- 
bled on  walking.  Her  physician  referred  her  to  the 
clinic. 

Status  praesens:  L.e. :  Noticeable  facial  paresis.  Ex- 
tensive otitis  externa,  preventing  otoscopic  examination. 
R.e. :  Drumhead  thickened  anteriorly,  very  atrophic  and  re- 
tracted posteriorly. 

Functional  test:  R.e.:  Nearly  normal.  L.e.:  Tested  with 
exclusion  apparatus,  deaf  for  speech  and  tuning  forks. 
W.  1.,  R.  — ,  Sch.  lengthened.  Spont.  ny.  rotat.  r.  Cal.  re- 
act.: It  cannot  be  determined  whether  or  not  the  spont. 
rotat.  ny.  r.  is  increased  by  the  irrigation.  Fistula  symp- 
tom: Excessive  movement  of  the  eyes  prevents  a  satisfac- 
tory test. 

Oct.  2:  No  caloric  react,  (cold  water).  Fistula  test  can- 
not be  made.  Spont.  ny.  perhaps  a  little  less.  Otitis  ex- 
terna less.    No  fever. 

Oct.  4 :  Spont.  ny.  rotat.  r.  as  marked  as  before.  Fistula 
test  cannot  be  satisfactorily  made.  Cal.  test :  One  irrigator 
full  of  cold  water  causes  no  change  in  the  spont.  ny.    De- 


CASE  HISTORIES  209 

creased  otitis  externa  i^ermits  one  to  see  a  total  destruc- 
tion of  the  drum;  cholesteatoma;  the  probe  touches  bare 
bone.  Upper  wall  of  meatus  slightly  swollen.  Serous, 
haemorrhagic  discharge.  Deaf  (tested  with  exclusion  ap- 
paratus). Turning  test  cannot  be  satisfactorily  made  on 
account  of  the  severe  spont.  ny.  rotat.  r. 

Operation,  Oct.  5  (Prof.  Urbantschitsch) :  Mastoid  ex- 
tensively destroyed  beneath  the  surface.  Granulations  and 
masses  of  cholesteatoma  in  the  antrum.  Dura  of  the  poste- 
rior fossa,  which  is  covered  with  granulations,  is  laid  bare. 
Sinus,  laid  bare,  is  only  slightly  altered.  An  abnormal  con- 
nection between  the  lateral  sinus  and  the  petrosal  sinus. 
The  angle  is  removed.  Typical  radical.  In  the  horizontal 
semicircular  canal  is  an  elongated,  discolored  fistula,  2  mm. 
long.  Typical  labyrinth  operation.  The  horizontal  portion 
of  the  facial  nerve  lies  free  in  the  tjTnpanic  cavity. 

Oct.  10 :  First  change  of  dressing.  Sutures  left  in  place. 
Dressing  every  other  day.  Suppuration  slight.  Small  se- 
questra are  thrown  off. 

Oct.  22:  Transferred  to  O.P.  Dept.  Temperature  has 
been  alwavs  normal. 

90.  K.  P.  Age  22.  Admitted  Feb.  4,  1910. 

Anamnesis:  R.e. :  Was  always  normal.  Discharge  from 
I.e.  for  fourteen  5^ears,  occasionally  stopping  for  a  short 
time.  Since  Jan.  20  there  have  been  severe,  tearing  pains, 
particularly  at  night.  No  headache  or  emesis.  Measles  at 
age  9.  One  year  before,  glands  behind  I.e.  swelled,  and  after 
fourteen  days  broke  and  discharged,  but  healed  over  after 
two  or  three  weeks.  This  recurred  every  two  or  three 
months,  lasting  for  one  or  two  weeks,  until  his  fourteenth 
year.  Thereafter  no  more  retro-auricular  suppuration.  The 
suppuration  of  the  I.e.  began  with  the  glandular  suppura- 
tion, and  continued,  except  for  short  intervals,  until  now. 
No  pains  until  Jan.  20,  1910 ;  never  any  vertigo  or  nausea, 
and,  he  says,  no  fever.  Always  well  (labored  as  farmer 
until  admitted).    External  ear  never  affected.    Mother  died 


210  DISEASES  OF  THE  LABYRINTH 

of  ' '  catarrh  of  lungs ' '  at  38.    Father  well.    One  brother  and 
one  sister  always  well.    Moderate  drinker.    Denies  lues. 

Status  praesens:  K.e. :  Hammer  prominent  and  fore- 
shortened. In  front  of  the  hammer,  an  elongated  calcifica- 
tion. Function  normal.  L.e. :  A  little  pus  in  the  canal.  The 
posterior  meatal  wall  is  so  swelled  that  it  touches  the  ante- 
rior wall. 

Functional  test:  L.e.:  Tested  with  exclusion  apparatus, 
deaf  for  speech  and  tuning  forks.  W.  1.,  R.  — ,  Sch.  shor- 
tened. No  spont.  ny.  No  fistula  sympt.  Cal.  react,  not 
demonstrable.  After  tr.  1.,  ny.  horiz.  r.  =  21".  After  tr.  r., 
ny.  horiz.  1.  =  l"-2".    Temp.  39.2. 

•  Operation,  Feb.  5  (Ernst  Urbantschitsch) :  On  retract- 
ing the  periosteum,  the  outer-  wall  of  the  mastoid  appears 
to  be  inflated  and  approximates  the  anterior  meatal  wall. 
On  opening  this  cyst-like  bone,  whose  wall  is  only  about 
2  mm.  thick,  a  decomposed  pulsating  cholesteatoma  pours 
forth.  On  sponging,  there  is  repeated  facial  twitching. 
After  removing  the  posterior  meatal  wall,  we  see  the  tym- 
panic cavity  invaded  by  the  cholesteatoma,  which  extends 
even  into  the  tube.  The  ossicles,  including  the  stapes,  are 
gone.  Granulations  in  the  oval  window.  The  probe  passes 
easily  into  the  labyrinth.  In  the  horizontal  canal,  a  large 
fistula,  with  granulations,  into  which  an  ordinary  ear  probe 
cannot  be  passed.  No  reaction  upon  pressure  on  the  fistula 
opening,  nor  after  hot  and  cold  irrigation.  Typical  laby- 
rinth operation.  Escape  of  cerebrospinal  fluid.  Dura  of 
the  middle  fossa  very  prominent.  Wall  of  sinus  (already 
exposed)  somewhat  thickened  and  covered  with  granula- 
tions. Considering  this  fact,  and  also  the  elevation  of  tem- 
perature, the  sinus  is  opened,  and  found  to  be  entirely  free 
from  blood  and  thrombi  and  having  a  lumen  the  size  of  a 
quill. 

Feb.  6:  Comfortable.  No  spont.  ny.  or  vertigo.  Head- 
ache much  better;  no  nausea.  Flow  of  cerebrospinal  fluid. 
Facial  paresis,  but  the  1.  eye  can  be  half  closed.    Temp.  37.4. 


CASE  II I  STORIES  211 

Feb.  7  and  8 :  Comfortable.  Sleep  and  nourishment  sat- 
isfactory.   Normal  temp. 

Feb.  10 :  First  change  of  dressing.  No  free  pus.  Wound 
healing  well, 

Feb.  11-16:  Healing  progressing  favorably;  no  free  pus 
in  the  tympanic  cavity.  Facial  nerve  paralyzed  in  its  lower 
division,  while  there  is  only  paresis  of  the  upper  division 
(1.  eye  can  be  more  than  half  closed). 

Feb.  18-22:   Normal  course.    Feels  exceedinglv  well. 

Feb.  23-28:  Condition  as  above. 

Mch.  4 :  Transferred  to  O.P.  Dept. 

Report  on  pus  (Prof.  Ghon) :  Microscopically,  an  abun- 
dant conglomeration  of  bacteria:  1.  Gram-positive  cocci  in 
pairs  in  short  chains,  round  and  elongated.  2.  Gram-posi- 
tive bacilli  of  the  fusiform  type.  3.  Gram-positive  bacilli  in 
capsules.  4.  Gram-positive  bacilli  of  variable  breadth  and 
thickness.  5.  Gram-positive  bacilli  with  club-shaped  end§. 
6.  No  acid  fixing  bacteria. 


91.  E.  M.  Age  8.  Admitted  Feb.  15,  1910. 

Anamnesis:  Discharge  from  I.e.  during  past  year.  Then 
an  abscess  formed  behind  the  ear,  with  vertigo  and  head- 
ache, which  at  once  improved  when  the  abscess  broke.  No 
fever,  emesis  or  vertigo. 

Status  praesens:  L.e.:  Normal.  R.e. :  Behind  the  pinna, 
a  radiating  tear,  in  part  adherent  to  the  bone.  Upon  the 
scar  lies  a  brownish  crust.  Drumhead  swelled,  reddened, 
with  a  perforation"  in  the  anterior  inferior  quadrant.  Gran- 
ulations. 

Functional  test:  With  exclusion  apparatus  r..  I.e.:  Deaf. 
W.  1.,  R.  — ,  Sch.  shortened.     C,  +,  c^  +.    No  vertigo. 
Spont.  ny.  r.  not  always  clearly  rotatory,  to  the  1.  slight, 
more  horiz.     No  fistula   sympt.     Cal.  react.:  The  spont. 
rotat.  ny.  r.  is  increased  ( ?).    No  vertigo. 

Operation,  Feb.  17  (Prof.  Urbantschitsch) :  Typical  radi- 


212  DISEASES  OF  TEE  LABYRINTH 

cal.  No  fistula  of  the  labyrinth  to  be  seen.  Test  under  the 
anaesthetic.    Tj'pical  labyrinth  ojieration. 

Feb.  18,  temp.  37.5;  Feb.  19,  37.0;  Feb.  20,  36.9-37.8;  Feb. 
21,  36.2,  37.7;  from  Feb.  22,  normal. 

Feb.  23:  First  change  of  dressing.  Moderate  suppura- 
tion, with  slight  tendency  to  granulate. 

Feb.  28:  Transferred  for  after-treatment  in  the  O.P. 
Dept. 

92.  E.  L.  Age  32.  Admitted  Mch.  5,  1910. 

Anamnesis:  Two  years  ago  patient  noticed  a  bloody  dis- 
charge from  I.e.,  with  vertigo  and  headache.  In  Warsaw, 
where  he  went  eight  days  ago,  a  small  operation  is  supposed 
to  have  been  performed.  Patient  complains  of  vertigo, 
headache  and  nausea. 

Status  praesens:  R.e. :  Drumhead  retracted,  scars  in 
front  of  and  behind  the  hammer.  Function  normal.  L.e. : 
Drumhead  swollen  and  red  in  its  upper  portion.  Attic  fis- 
tula; central  perforation,  with  small  granulations. 

Functional  test:  L.e.:  Deaf  for  speech  and  tuning  forks. 
W.  in  head,  R.  — ,  Sch.  greatly  shortened.  No  sjwnt.  ny., 
no  fistula  sympt.  Calor.  react,  not  demonstrable.  After  tr. 
r.,  ny.  horiz.  1.  =  2"-4".    After  tr.  1.,  ny.  horiz.  r.  =  15". 

Operation,  Mch.  9  {Ruttin) :  Mastoid  sclerotic.  Antrum 
deep  and  containing  many  granulations.  Typical  radical 
operation.  Horizontal  semicircular  canal  flattened,  with 
exostosis,  with  an  irregular  groove  in  the  middle.  Typical 
labyrinth  operation.  The  horizontal  canal  carefully  exam- 
ined, but  no  lumen  found.  It  is  plainly  filled  by  bony  hyper- 
plasia. Vestibule  opened  from  behind  without  exposure  of 
the  dura.  The  probe  passes  through  the  oval  window  and 
emerges  under  the  facial.  No  twitching  during  the  opera- 
tion. Promontory  removed.  No  cerebrospinal  fluid.  Plas- 
tic. During  the  operation  the  caloric  test  was  made  with 
cold  water,  without  the  slightest  reaction.  Wick  in  front 
of  and  behind  the  facial. 

Mch.  20 :  After  the  operation,  absolutely  no  ny.  or  laby- 


CASE  niSTOBIES  213 

rinth  symptoms.    No  vertigo.    Only  the  first  few  days,  head- 
ache.    Timiitus. 

Apr.  28:  After  a  normal  course,  transferred  for  treat- 
ment to  the  O.P.  Dept.    Temperature  always  normal. 

93.  Sch.  K.  Female.  Age  27.  Admitted  Apr.  19,  1910. 

Anamnesis:  For  one  year,  discharge  from  ear,  with  in- 
termissions. One  month  ago,  an  attack  of  vertigo.  Since 
then,  often  slight  vertigo.  Ten  days  ago,  patient  noticed 
facial  paralysis.    Tinnitus. 

Status  praesens:  K.e. :  Total  destruction  of  drumhead. 
Granulations  in  the  tympanic  cavity.  L.e. :  Almost  com- 
plete destruction  of  the  drumhead.  No  ossicles.  Granula- 
tions. 

Functional  test:  L.e.:  Nearly  normal.  R.e. :  Tested  with 
exclusion  apparatus,  deaf  for  speech  and  tuning  forks. 
W.  1.,  R.  — ,  Sch.  shortened.  Spont.  ny.  rotat.  and  horiz, 
r.  :=  ny.  rotat.  1.  No  fistula  sympt.  Cal.  test  gives  no  re- 
sponse. After  tr.  1..  ny.  horiz.  =  10".  After  tr.  r.,  ny.  horiz. 
1.  ^.  40". 

Operation,  Apr.  22  (Dr.  Bondy) :  Radical  operation.  No 
ossicles.  Abundant  granulations  in  the  antrum  and  in  the 
tympanic  cavity.  Large  fistula  in  the  horizontal  canal,  filled 
with  granulations.  It  surrounds  the  eminence  of  the  canal 
like  a  horseshoe.  The  probe  does  not  enter  deeply  into  the 
vestibulum.  Posterior  fossa  laid  bare.  The  overhanging 
edges  of  the  fistula  removed  with  the  chisel.  Vestibulum 
widely  opened  from  behind.  As  the  entire  facial  ridge  ap- 
pears to  be  necrotic  and  the  probe  can  be  introduced  deeply 
beneath  it,  a  restoration  of  the  function  of  the  facial  nerve 
seems  unlikely;  accordingly,  the  entire  facial  prominence 
is  removed  to  the  level  of  the  base  of  the  fistula  to  expedite 
healing.  Promontory  opened.  Plastic  after  Stacke,  lower 
flap  sutured.    Dressing. 

Apr.  23 :  Feels  well.  Ny.  like  before  the  operation.  No 
vertigo.    No  fever. 

Apr.  28 :  First  change  of  dressing.    Wound  unirritated. 


214  DISEASES  OF  THE  LABYRINTH 

May  24 :  Wound  cavity  gTaiuilatiiig.  Moderate  secretion. 
Discharged.    Tinnitus  persists.    Temp,  always  normal. 

94.  K.  C.   Female.   Age  19.  Admitted  Apr.  29,  1910. 

Anauuiesis:  Was  blind  until  her  sixth  year.  No  chil- 
dren's diseases.  R.e.  has  discharged  continuously  for  eight 
years.  Eight  days  ago,  a  polyp  was  removed;  since  then, 
patient  noticed  that  her  face  is  asymmetrical  and  she  can- 
not entirely  close  the  right  eye.    There  was  also  fever. 

Status  praesens:  L.e. :  Calcification  and  scars.  R.e.: 
Posterior  superior  wall  of  canal  swollen.  In  the  tympanic 
cavity,  many  soft  granulations,  whicli  lileed  easily.  In  the 
canal,  thick,  bad-smelling  i)us.  Fhictuating  mass  beliind 
ear.    Temp.  37.1.    Pulse  96. 

Functional  test:  With  exclusion  apparatus  1.,  r.  ear  is 
deaf.  W.  1.,  Ci  0,  c^  0.  Spont.  ny.  r.  =  1.  No  fistula  symp- 
tom. Cal.  react.  0.  Nervous  system  normal,  except  for 
facial  paresis  of  all  divisions.  Slight  ataxia  of  the  upper 
r.  extremity. 

Operation,  May  4  (Prof.  Urhantschitsch) :  Typical  radi- 
cal. In  the  horizontal  canal,  a  discolored  fistula,  2  mm.  long. 
The  sinus  and  the  dura  of  the  posterior  fossa  laid  bare. 
These  are  normal.  Typical  labyrinth  operation  after  Neu- 
mann. 

May  10 :  First  change  of  dressing.  Some  pus  behind  the 
labyrinth.  Normal  course.  Temp,  practically  normal  after 
May  9. 

95.  L.  S.  Male. 

Smallpox  in  fifth  year.  Discharge  was  first  noticed  on 
entering  military  service;  lasted  until  Jan.  of  this  year, 
being  continuous  and  moderate  in  quantity.  Since  Jan.,  in- 
creased suppuration.  No  headache  or  vertigo.  During  the 
past  seventeen  days,  severe  pain,  so  that  patient  could  not 
sleep.    L.e.  always  well.     Never  any  tinnitus  or  vertigo. 

Status  praesens:  L.e.  normal.  Very  offensive  discharge. 
Posterior  meatal  wall  very  low  and  granulating,  prevent- 


CASE  HISTORIES  215 

ing  further  examination.  Mastoid  tip  quite  tender  upon 
pressure. 

Fnnctio7ial  test:  Deaf  for  speech  and  tuning  forks 
(tested  with  exclusion  apparatus).  W.  in  head.  R.  co  — , 
Sch.  not  shortened.  Slight  spont.  ny.  to  both  sides.  No 
fistula  sympt.  No  cal.  react.  Tr.  react.:  After  tr.  1.  rm  0; 
after  tr.  r.,  typical.  Pupils  equal,  react  promptly  to  light 
and  accommodation.  Reflexes  active,  no  disturbances  of 
sensibility,  no  ataxia.     Intelligence  unaffected.    Pulse  100. 

Operation,  July  25  {Ruttin) :  Mastoid  very  sclerotic. 
Cholesteatoma  in  antrum.  In  the  horizontal  canal,  a 
grayish-red  fistula,  the  size  of  a  pinhead.  Oval  window 
empty,  the  probe  entering  A\ithout  resistance.  Labyrinth 
opened  from  behind  without  exposure  of  the  dura  of  the 
posterior  fossa.  The  anaesthetist  reported  repeatedly  dur- 
ing the  entire  operation  that  there  was  no  facial  twitching. 
Promontory  removed.  No  cerebrospinal  fluid.  Sinus  and 
dura  of  the  middle  and  posterior  fossae  not  exposed.  Plas- 
tic.   Dressing.    After  the  operation,  slight  facial  paresis. 

July  26:  Paresis  somewhat  increased. 

July  27 :  Paresis,  still  greater. 

July  31 :  Normal  course.  Wound  in  good  condition,  little 
discharge. 

Aug.  2:  Paresis  the  same. 

Aug.  6:  Transfererd  to  O.P.  Dept.  Temp,  at  all  times 
normal. 

96.  F.  K.   Male.   Age  37. 

Anamnesis:  Discharge  from  both  ears  since  childhood. 
Hearing  reduced  on  both  sides,  especially  r.  Two  weeks 
ago,  sudden  high  fever,  and  was  in  bed  eight  days.  On  get- 
ting up,  he  had  severe  vertigo,  so  that  he  could  not  stand. 
Had  headache  during  the  fever.  No  emesis.  Temp.,  July 
29 :  36.6,  36.4. 

Status  praesens:  L.e. :  Fetid  discharge.  Polyp,  size  of 
a  pea,  in  canal.    R.e. :  Complete  destruction  of  drumhead. 


216  DISEASES  OF  THE  LABYRINTH 

Fetid  sui)piiration.  Fistula  into  antrum.  Hammer  imbed- 
ded in  a  polyp.-like  swelling. 

Functional  test:  L.e. :  Con.v.  2  m.,  whisp.  a.c,  W.  1.,  R.  — , 
Sch.  greatly  shortened.  C,  0,  c*  shortened.  No  fistula 
symptom.  Cal.  react,  typical.  R.e. :  Tested  with  exclusion 
apparatus:  Deaf  for  speech  and  tuning  forks.  Xo  spont. 
ny,  Cal  react,  could  not  be  elicited.  After  tr.  r.,  ny.  horiz. 
l/=  20".    After  tr.  1.,  ny.  horiz.  r.  =  0. 

Operation,  July  29  {Ruttin)  :  Mastoid  very  sclerotic. 
Typical  radical.  Cholesteatoma  in  antrum.  Labyrinth 
opened  from  behind  without  exposing  the  dura.  Labyrinth 
wall  inspected  after  action  of  tonogen.  In  the  horiz.  semi- 
circular canal,  no  fistula.  Oval  window  empty.  Granula- 
tions visible  upon  opening  the  promontory.  No  flow  of  laby- 
rinthine fluid.  No  exposure  of  dura  or  sinus.  Plastic.  Fa- 
cial, after  the  operation,  intact. 

Aug.  2:  First  change  of  dressing.  Wound  clean,  little 
discharge.  Granulations  forming.  No  suggestion  of  ny., 
no  vertigo,  no  headache. 

Ang.  12 :  Wound  normal.  Patient  feels  well.  Dismissed, 
to  be  dressed  in  O.P.  Dept. 

97.  S.  G.  Male.  Age  19.  Admitted  Oct.  14,  1907. 

Anamnesis:  Patient  has  had  an  ear  suppuration  from 
childhood,  which  supposedly  began  after  a  vaccination, 
stopped  at  intervals,  only  to  begin  again.  Headache  for 
about  six  months,  which  at  first  was  on  the  left  side,  later 
more  diffuse.  Four  attacks  of  vertigo  within  the  past  three 
months.  With  such  an  attack  comes  the  feeling  as  if  his 
legs  were  like  lead.  Then  he  collapses,  and  is  dazed,  when 
he  is  dizzy.  The  last  attack,  early  in  October.  Hearing  1. 
very  poor  since  childhood. 

Status  praesens:  L.e.:  Drumhead  totally  destroyed,  a 
small  defect  in  the  lateral  attic  wall.  The  head  and  poste- 
rior leg  of  the  stapes  is  visible.  Tympanic  cavity  covered 
with  granulations.    Purulent  discharge  in  the  meatus.    The 


CASE  HISTORIES  217 

inf ra-aiirieular  gland  somewhat  sensitive  to  pressure.  R.e. : 
Calcifications. 

Functional  test:  R.e.:  Whisp.  6  m.  AV.  r.,  R.  — ,  Sch. 
lengthened.  Ci  +,  c*  +.  L.e. :  Con.v.  3  m.  Whisp.  5  cm. 
R.  — ,  Sch.  not  shortened,  spont.  ny.  1.  Cal.  react.  +.  After 
tr.  r.,  ny.  horiz.  1.  =  25".  After  tr.  1.,  ny.  horiz.  r.  =  25" ; 
also  equal  with  head  forward.  For  I.e.,  c^,  when  lightly 
struck  with  the  finger,  is  negative.  When  struck  somewhat 
harder  it  is  positive.  With  the  conversation  tube,  the  pa- 
tient repeats  accurately  easy  words  when  whispered;  diffi- 
cult words  are  lost. 

Operation  (Prof.  Urbantschitsch) :  Radical  operation. 
Nothing  of  note. 

Oct.  22 :   First  dressing.    Wound  normal. 

After  leaving  hospital,  felt  well  for  five  days.  Oct.  27, 
severe  unilateral  headache  occurred,  lasting  the  entire  day. 

Oct.  29:  A.M.,  severe  vomiting,  combined  with  vertigo, 
so  that  he  could  not  raise  himself  up  in  bed.  Dr.  Bondy 
was  called,  and  ordered  him  taken  to  the  hospital. 

Status  praesens:  Operation  wound  granulating  nicely. 
Canal  no  longer  visible.  Spont.  rotat.  ny.  to  the  healthy 
side.  Cal.  react,  not  to  be  elicited.  L.e.:  Con.v.  0,  even 
with  the  conversation  tube. 

Nov.  5 :  No  ny.  on  looking  toward  the  well  side ;  on  look- 
ing to  the  1.,  rotat.  ny.  1.  Warm  irrigation  produces  in- 
crease of 'the  ny.  on  looking  to  the  diseased  side.  Cold  irri- 
gation gives  a  reversal  of  the  ny. 

Nov.  6 :  Whisp.  0.  Moderate  con.v.  is  heard  through  con- 
versation tube.  Tuning  fork  not  perceived.  Vertigo  some- 
what better.  Patient  leaves  the  hospital  to  be  treated  as  out- 
patient. 

Nov.  11 :  Had  vertigo  and  vomiting  yesterday. 

98.  W.  B.  Age  21.  Admitted  Nov.  1,  1908. 
Anamnesis :  Discharge  from  I.e.  seven  years  ago,  which 
ceased.     Two  years  ago,  again   a  discharge,  which  also 


218  DISEASES  OF  THE  LABYRIMH 

ceased.  Seven  days  ago,  severe  pain,  followed  by  discharge 
and  relief. 

Status  praesens:  R.e. :  Normal.  L.e. :  Marked  swelling, 
redness  and  bulging  of  the  drum,  particularly  in  its  upper 
parts.  Perforation  in  anterior  inferior  quadrant.  Canal 
swelled  and  red.  Mastoid  sensitive  to  percussion  and 
pressure. 

Nov.  2 :  Evening  temp.  39.9.    A.M.,  37.0. 

Functional  test:  L.e.:  Con.v.  3 — 4  m.,  whisp.  1  m.  W.  1., 
R.  — ,  Sell,  lengthened,  Ci  +,  c^  +.  No  vertigo,  no  spont. 
ny.  No  fistula  sympt.  Cal.  react,  prompt.  Local  symp- 
toms grow  less.  Temp,  remains  at  39.5.  Evening,  pain  in 
knee-joint. 

Nov.  4:  Attack  of  inflammatory  rheumatism  (?).  Trans- 
ferred to  medical  ward. 

Nov.  5 :  Returned,  no  fever.  Mastoid  intensely  sensitive 
to  pressure.    Abundant  discharge. 

Operation  (Bondy) :  Simple  opening  of  mastoid.  Entire 
mastoid  diseased,  with  large  cavity  in  lower  part,  contain- 
ing many  granulations  and  pus.  Sinus  lies  exposed  in  the 
cavity  and  is  covered  with  deposits.  Antrum  widely  opened. 
Filled  with  granulations,  invading  also  the  tympanic  cav- 
ity. Radical  operation.  Dura  widely  exposed.  Mastoid 
emissary  vein  cut  in  trying  to  ligate.  No  haemorrhage. 
Thrombosed.  Because  of  absence  of  fever,  operation  car- 
ried no  further.  Pause  plastic.  P.  M. :  Repeated  emesis. 
No  vertigo  or  ny.    Temp.  36.8. 

Dec.  10:  Feels  well.    Temp.  36.4. 

Dec.  11:  No  emesis. 

Dec.  12:  Ny.  to  the  operated  side,  and  emesis  on  chang- 
ing position.  P.M.:  Ny.  to  the  diseased  side,  but  only  on 
changing  his  position.  When  he  is  quiet,  no  symptoms  or 
feeling  of  being  ill,  lies  always  upon  the  well  side.  Fundus 
normal  (Dr.  0.  Ruttin). 

Dec.  13:  No  emesis,  vertigo  or  ny. 

Dec.  14:  First  change  of  dressing.  Patient  able  to  get 
from  bed  to  carriage  without  nausea  or  vertigo.     Wound 


CASE  IIJSTORIES  219 

normal.  Very  severe  cold  water  ny.  after  only  very  slight 
irrigation.  Whisp.  apparently  heard.  Con.v.  (with  exclu- 
sion apparatus)  with  mistakes. 

Dec.  19:  Patient  feels  entirely  well;  no  ny.,  no  equilib- 
rium disturbances.  Wound  cavity  beginning  to  granulate. 
Dismissed  to  O.P.  Dept. 

99.   K.  G.   Age  15.   Admitted  Mch.  13,  1908. 

Anamnesis:  Diphtheria  three  years  ago.  Since  then,  con- 
tinuous discharge  from  both  ears.    No  vertigo  or  headache. 

Status  praesens:  R.e. :  Meatus  greatly  narrowed,  very 
fetid  discharge,  a  large  polyp  deep  in  the  canal  hides  drum- 
head. Swelling  behind  and  below  ear  (glandular  abscess?). 
L.e. :  Canal  also  narrow.  Granulations  and  pus.  No  swelling 
over  mastoid.    No  fever.    No  internal  disease. 

Functional  test:  R.e.:  Con.v.  5  m.,  whisp.  V^  m.,  W.  r., 
R.  — ,  Sch.  lengthened,  Ci  0,  c*  +•  Cal.  react,  prompt. 
L.e.:  Con.v.  3  m.  Whisp.  50  cm.  R.  — ,  Sch.  lengthened. 
Ct  4-,  c*  +.  Cal.  react,  prompt.  No  vertigo,  spont.  ny.  or 
fistula  sympt. 

Operation,  r.,  Mch.  16  (Prof.  Urhantschitsch) :  Glandular 
abscess  emptied.  Mastoid  softened  so  that  sinus  had  to  be 
laid  bare.  Typical  radical  operation.  Hammer  partly  de- 
stroj'ed,  anvil  not  found.  Evening:  Feels  well.  Gets  out 
of  bed.    Xo  vertigo. 

Mch.  17 :  At  2  A.M. :  Sudden  severe  nausea.  4  A.M. :  Re- 
peated vomiting.  Forenoon :  Vertigo,  emesis,  especially  on 
sitting  up.    Spont.  ny.  rotat.  1. 

Mch.  18:  Vertigo,  spont.  ny.  rotat.  1.  on  looking  to  1.  and 
ahead.    Lies  on  left  side. 

Mch.  19 :  Condition  the  same.    Ny.  decidedly  less. 

Mch.  20:  Temp.  39.2.  No  vertigo.  Spont.  ny.  only  on 
looking  to  1.  Lies  upon  back.  No  headache.  Dressing. 
Wound  covered  with  exudate,  purulent  near  sinus.  Pulsa- 
tion in  region  of  sinus.  Abundant  pus  in  the  opened  ab- 
scess. Hears  middle  fork  at  right  ear  with  only  slight  re- 
duction.   Ci  +,  c^  -f .    W.  r.    Cal.  react,  prompt. 


220  DISEASES  OF  THE  LABYRINTH 

Mch.  21 :  Condition  the  same.     Temp.  39.6. 
Meh.  22:  Lies  upon  back.     Ny.  only  on  looking  to  ex- 
treme 1.    Temp.  37.7. 

Mch.  23:  Same.     Temp,  normal. 
Mch.  24:  No.  ny.     Feels  well. 
Mch.  26:  Transferred  to  O.P.  Dept. 

100.  O.  L. 

Anamnesis :  Eight  years  ago,  without  previous  pain,  dis- 
charge from  both  ears,  which  continued  in  variable  amount 
until  two  weeks  ago,  when  he  took  treatment.  R.e.  im- 
proved. Since  July  16,  vertigo  on  moving.  No  headache 
or  emesis. 

Status  praesens :  Very  bad-smelling,  abundant  discharge 
from  both  ears.  R.e.:  Perforation  in  Shrapnell's  mem- 
brane, probably  defect  in  lateral  attic  wall.  L.e. :  Large 
perforation  in  posterior  inferior  quadrant ;  a  second  one  in 
Shrapnell's  membrane. 

Functional  test:  R.e.:  Con.v.  7  m.,  whisp.  4  m.,  Sch.  nor- 
mal. No  fistula  sjTnpt.  Cal.  react,  prompt.  L.e.:  Con.v. 
1  m.,  Sch.  normal.  Con.v.,  through  con.  tube,  good,  even 
when  conversation  is  going  on  about  patient.  Wliisp.  the 
same.  W.  in  head;  on  closing  I.e.,  lateralized  to  1.  R.e. 
negative.  Bone  conduction  1.  nearly  normal.  When  sound 
is  gone  with  the  fork  on  the  mastoid,  closing  the  left  ear 
causes  the  sound  to  reappear.  Ci  (Bezold),  heard  by  nor- 
mal ear  when  heavily  struck  45",  is  heard  for  11";  c^ 
(Bezold),  struck  with  fingernail,  is  heard  less  than  normal 
time.  Exclusion  apparatus  in  r.e.:  Con.v.  heard  on  shout- 
ing, but  words  not  made  out.  c^,  when  made  to  vibrate  with 
fingernail,  0;  struck  with  metal,  -f.  Ci,  when  heavily 
■struck,  4".  Wliistles  all  heard.  No  fistula  sjTnptom.  Cal. 
react,  prompt.  Spont.  ny.  strong  upon  looking  to  r.,  weak 
on  looking  to  1. 

Operation,  July  21  (Bondy) :  Typical  radical  operation. 
Antrum  quite  small,  filled  with  granulations.  Sinus  laid 
bare  over  small  area.    Its  wall  normal.    Diseased  bone  re- 


CASE  HISTOIUES  221 

moved  to  the  middle  fossa ;  dura  laid  bare  size  of  a  lentil ; 
normal.  Horizontal  canal  normal.  Granulations  in  the  tym- 
panic cavity.  Remnant  of  hammer  and  part  of  anvil  found. 
Panse  plastic.    Retro-auricular  suture. 

July  26 :  Facial  paresis.    Feels  well. 

Aug.  1 :  First  change  of  dressing.  Wound  normal,  gran- 
ulating; no  discharge.  Small  abscess  in  lower  angle  of 
wound.    Dismissed. 

101.  A.  V.  Ph.  Age  38.  Admitted  Feb.  20,  1909. 

Anamnesis:  Deafness  and  tinnitus  for  one  year.  Four 
months  after  onset,  discharge.  After  irrigation  of  ear, 
haemorrhage  from  ear  and  nose.  Never  headache.  For  one 
week,  pain  in  the  region  of  the  ear.  Never  vertigo  or 
emesis. 

Status  praesens:  R.e. :  Normal.  L.e. :  Attic  suppuration, 
drum  red  and  swollen. 

Functional  test:  L.e. :  Con.v.  1  m. ;  whisp.  0.  Tested  with 
exclusion  apparatus  r. :  Con.v.  1/2  m.  W.  in  head,  R.  — , 
Sch.  lengthened,  Ci  and  c^  feebly  heard.  No  vertigo,  spont. 
ny.  or  fistula  sympt.    Cal.  react,  typical.    Tinnitus. 

Operation,  Feb.  2.3:  Typical  radical.  Pus  and  granula- 
tions in  the  antrum.  Nothing  peculiar  in  the  anatomical 
conditions. 

Feb.  24:  Temp.  37.8.    Pain.    P.M.:  39.0. 

Feb.  25:  Temp,  normal. 

Feb.  26:  A.M.,  temp.  38.1.  10  A.M.,  patient  complains  of 
vertigo  and  soon  vomits.  Large  rotat.  ny.  to  healthy  side. 
Dressing  changed.  Abundant  discharge.  Postauricular 
wound  opened.  With  exclusion  apparatus  (applied  to  r.e.), 
totally  deaf.  Irrigation  with  warm  water  (46°)  soon  causes 
vertigo  and  ny.  to  diseased  side.  Slight  swelling,  redness 
and  pain  below  the  mastoid.  7  P.M. :  Typical  labyrinth  op- 
eration (Bondy).  Sinus  and  dura  of  middle  and  posterior 
fossae  laid  bare.  The  small  burrowing  abscess  at  the  mas- 
toid tip  is  opened. 

Feb.  27 :  Vertigo  and  ny.  less.    Feels  better.    Temp.  40.3. 


222  DISEASES  OF  THE  LABYRINTH 

Evening:  Distinct  signs  of  meningitis.  Incision  of  the  dura 
of  the  middle  fossa  and  puncture  of  the  parietal  lobe. 

Feb.  28:  Death. 

Postmortem:  Puncture  of  the  1.  parietal  lobe  (at  10 
o'clock)  before  death  of  patient,  because  of  possibility  of 
an  abscess.  Destruction  of  a  portion  of  brain  the  size  of  a 
heller  piece,  with  haemorrhage  of  same  at  the  site  of  punc- 
ture, with  extensive  subdural  haematoma  over  the  base  and 
convex  surface  of  the  1.  hemisphere,  from  torn  leptomenin- 
geal  vessels  about  the  point  of  puncture.  Diffuse,  acute, 
purulent  leptomeningitis,  especially  1.  Gram-positive  cocci 
in  chains.    Degeneration  of  the  parenchyma. 

102.  B.  R.  Age  20.  Admitted  Mch.  2, 1909. 

Anamnesis :  Radical  operation  r.e.  three  years  ago.  Dis- 
charge did  not  entirely  cease,  but  diminished.  ]\[ch.  1  and  2 
he  felt  severe  vertigo,  could  not  hold  himself  erect,  lay  in 
bed.    Severe  vomiting. 

Mch.  2:  Presents  a  grave  appearance.  Severe  spont. 
rotat.  ny.  1.  (patient  was  operated  r.),  and  weaker  spont.  ro- 
tat.  ny.  r.  Irrigation  with  cool  water  causes  spont.  ny.  r.  to 
disappear;  whether  the  ny.  1.  is  thereby  increased  cannot 
be  determined.  Hearing  distance  for  con. v.  %  J^a.,  whisp. 
a.c. ;  with  exclusion  apparatus,  i/4  m.  and  a.c.  Temp.  38.1. 
Patient  put  to  bed.  5  P.M.:  Vertigo  less,  no  emesis,  ny. 
rotat.  1.  somewhat  less. 

Mch.  3:  Ear  cleansed.  Iodoform  packing  in  meatus. 
Temp.  36.8. 

Mch.  4 :  Patient  able  to  go  about  without  vertigo.  Very 
slight  ny.  to  both  sides.    Temp,  normal. 

Mch.  6 :   Transferred  to  O.P.  Dept. 

103.  H.  K.  Student. 

Anamnesis:  Operated  r.e.  four  years  ago.  Discharge 
continued,  though  less.  Occasionally  discharge  stops,  but 
returns  soon.  For  three  weeks,  vertigo,  especially  on  stand- 
ing up.    Headache,  pains  over  both  eyes ;  no  emesis. 


CASE  HISTORIES  223 

Status  praesens:  Apr.  7,  1909.  L.e. :  Drumliead  normal, 
except  for  a  calcification.  Cavity  of  a  radical  operation. 
Posterior  parts  covered  with  epidermis,  but  the  anterior 
part  (promontory)  is  not  covered. 

Functional  test:  Con.v.  (exclusion  apparatus  1.)  i/o  m., 
whisp.  a.c,  W.  r.,  R.  — ,  Scli.  lengthened,  Ci  O,  c^  0.  Spont. 
ny.  rotat.  1.  No  ny.  on  moving  head.  No  fistula  symptom, 
no  vertigo.  Cal.  react,  typical.  After  tr.  1.,  ny.  horiz.  r. 
=  30" ;  after  tr.  r.,  ny.  horiz.  1.  30".    No  fever. 

Apr.  13:  Small  spont.  ny.  rotat.  r.  appears;  attacks  of 
vertigo  have  ceased.    No  fever. 

Apr.  17:  Spont.  ny.  to  1.  continues.  Spont.  ny.  to  r. 
diminished.  Headache  still  present.  Dismissed  upon  his 
own  request. 

Apr.  14 :  R.e. :  Irrigated  with  very  cold  water,  ny.  rotat.  1., 
the  spont.  nj'.  persisting,  larger  and  also  present  on  look- 
ing forward,  which  was  not  the  case  before  irrigation.  Ex- 
clusion apparatus  1.,  hearing  distance  1/4  m.  for  con.v.,  W.  r., 
R.  exquisitely  — ,  Sch.  lengthened,  Ci  +,  when  lightly  struck, 
c^  +,  the  same.  After  tr.  r.,  ny.  horiz.  1.  =  19  oscillations  in 
16".    After  tr.  1.,  ny.  horiz.  r.  =  26  oscillations  in  15". 

Divided  kathode  —  anode  to  forehead  \ 
=  ny.  rotat.  r.  8-10  M.A. 

Divided  anode  —  kathode  to  forehead 
=  ny.  rotat.  1.  12  M.A. 

Anode  r.  —  kathode  to  forehead  =f  Carefully  tested 
ny.  rotat.  1.  10  M.A.  I  and  controlled  by 

Kathode  r.  —  anode  to  forehead  =f  reversing  elec- 
ny.  rotat.  r.  4  M.A.  1    trodes. 

Kathode  1.  —  anode  to  forehead  - 
ny.  rotat.  1.  6-8  M.A. 

Anode  1.  —  kathode  to  forehead  - 
ny.  rotat.  r.  6  M.A. 

104.  F.  W.  Female.  Age  20.  Admitted  Apr.  14,  1910. 
Anamnesis:  At  age  6,  measles;  otherwise  well,  except  for 
a  chr.  rhinitis.    Three  months  ago,  suppuration,  no  pains, 


224  DISEASES  OF  THE  LABYEINTE 

tinnitus  or  vertigo;  occasional  discharge  of  blood,  occa- 
sional attacks  of  fainting;  never  fever. 

Status  praesens:  E.e. :  Large  perforation  in  anterior  in- 
ferior quadrant,  a  small  one  in  the  anterior  superior  quad- 
rant.   Small  granulations  and  much  pus  in  the  meatus. 

Functional  test:  W.  r.,  R.  — ,  Ci  +,  c*  +.  No  vertigo  or 
spont.  ny.    No  fistula  sympt.    Cal.  react,  prompt. 

Operation  (Prof.  V  rh  ants  chit  sch) :  Mastoid  diploetic, 
antrum  of  moderate  size.  Cholesteatoma  in  attic  and  an- 
trum. Head  of  hammer  gone,  anvil  not  found.  Tj^ical 
radical  operation.    Pause  plastic. 

Apr.  15:  Patient  complains  of  severe  vertigo,  vomits 
much ;  lies  upon  the  healthy  side.  No  spont.  ny.,  but  rotat. 
ny.  to  both  sides  on  moving  the  head.    Difficult  micturition. 

Apr.  16 :  A.M. :  Severe  vertigo,  especially  upon  moving. 
Rotat.  ny.  r.    Nausea.    Must  be  catheterized. 

Apr.  17 :  Vertigo.    Ny.    Retention ;  catheter  twice  a  day. 

Apr.  18:  Vertigo,  retentio  urinae.  Ny.  rotat.  r.  and  1., 
stronger  to  r.  No  headache.  Lies  on  1.  side.  First  change 
of  dressing.  Wound  normal.  With  exclusion  apparatus, 
patient  hears  con.v.  2  m.,  W.  r.  Middle  fork  heard  next  to 
the  ear.    Ci  and  c*,  when  struck  gently,  -f .    Cal.  react,  -f. 

Apr.  19:  No  spont.  vertigo;  vertigo  only  on  sitting  up 
(before  Apr.  16,  17  and  18  it  was  present  with  eyes  open). 
Retentio  urinae.  No  vertigo.  Evening:  Spontaneous 
micturition. 

Apr.  20:  Feels  relatively  well.  Head  heavy.  Retentio 
urinae.    Apr.  21  like  Apr.  20. 

Apr.  22:  Second  change  of  dressing.  Wound  normal. 
Cal.  react.  +.  Patient  hears  (with  exclusion  apparatus) 
the  middle  tones  clearly,  but  the  high  and  deep  tones  are 
not  perceived.  Retentio  urinae.  No  vertigo.  Evening: 
Spontaneous  micturition. 

Apr.  23:  Nausea,  vomiting,  severe  vertigo.  Rotat.  ny. 
r.,  later  1. 

Apr.  24:  Feels  well  again. 


CASE  HISTORIES 


'SJ.O 


Apr.  25-28:  Everything  in  good  condition.  No  vertigo 
or  emesis,  occasional  ny.  rotat.  r.  and  ].    Out  of  bed. 

Apr.  29:  Transferred  to  O.P.  Dept.  Temp,  throughout 
normal. 

June  16:  R.e. :  Whisp.  1  m.  (exclusion  apparatus  1.).  W. 
in  head.  Middle  fork  heard  at  ear.  Spont.  ny.  1.  not  great. 
C,  +,  c^  +. 

After  tr.  1.,  ny.  horiz.  r.  =  12". 

After  tr.  r.,  ny.  horiz.  1.  =  14". 

105.  S.  K.  Age  30.  Admitted  Mch.  6,  1908. 

Anamnesis:  Discharge  r.e.  for  about  five  years.  Now 
and  then  vertigo.    No  headache. 

Stains  praesens:  L.e. :  Normal.  R.e.:  Meatus  narrowed. 
Posterior  superior  wall  bulges.  Destruction  of  drumhead. 
Attic  suppuration. 

Functional  test:  Con.v.  6  m.,  whisp.  2  m.,  W.  r.,  E.  +, 
Sch.  shortened,  Ci  +,  c^  +,  shortened.  Spont.  ny.  1.  on  look- 
ing to  1.,  but  r.  on  looking  to  r.  No  fistula  sympt.  Cal.  react, 
prompt. 

Operation,  Mch.  16 :  Large  cholesteatoma  in  mastoid,  but 
it  has  at  no  point  exposed  the  dura.  Radical  operation.  In 
smoothing  the  facial  prominence,  the  horizontal  semicircu- 
lar canal  is  opened.    Facial  twitching  twice.    Plastic. 

Mch.  17:  Patient  has  attacks  of  vertigo  and  vomiting 
upon  moving.  A  regular,  slow,  rolling  and  horizontal  move- 
ment of  both  eyes  on  looking  forward.  On  moving,  attacks 
of  ny.  rotat.  1.    At  times,  no  ny. 

Mch.  18 :  No  more  regular  rolling.    Ny.  rotat.  1.  marked. 

Mch.  22:  Ny.  rotat.  1.  moderate,  only  on  looking  to  1. 
Patient  is  up;  goes  about  with  confidence;  does  not  com- 
plain of  vertigo. 

Mch.  23:  First  change  of  dressing.  Wound  looks  well. 
Tested  with  exclusion  apparatus,  he  hears  sounds,  but  no 
speech. 

Mch.  26:   Wound  granulating  well.     The  wounded  part 


226  DISEASES  OF  THE  LABYRINTH 

of  horizontal  canal  still  visible.     Vertigo  very  slight.     Xo 
ny.    Temperature  has  always  been  normal. 

106.  R.  L.  Male.  Age  15. 

Anamnesis :  For  several  years,  discharge  r.  Increased 
discharge  during  past  few  weeks. 

Status  praesens:  L.e. :  Drumhead  retracted.  E.e.:  Large 
perforation,  with  drumhead  adherent  to  promontory.  Lit- 
tle discharge. 

Functional  test:  Con.v.  SVn  m.,  whisp.  I/2  ^;  W.  r..  R.  — , 
Sch.  lengthened,  C,  -!-,  c^  +.  No  vertigo  or  spont.  ny.  No 
fistula  sjTupt.    Cal.  react,  prompt. 

Operation,  Feb.  9,  1908:  Radical  operation.  Dura  of  the 
middle  fossa  laid  bare.    Plastic,  packing. 

Feb.  9 :  Temp.  38.1.  Ny.  rotat.  1.  vrii\\  eyes  in  any  posi- 
tion. Retching  and  vomiting.  Lies  upon  the  diseased  side. 
Vomiting  upon  sitting  up.  Dressing  changed.  Dura  looks 
well,  no  exudate.  But  the  inner  wall  of  tympanic  cavity  is 
discolored.  Functional  test:  No  change  of  the  ny.  rotat.  1. 
after  applying  gauze  strip  soaked  in  hot  saline,  nor  after 
dropping  hot  saline  into  the  cavity.  W.,  with  medium  fork, 
in  the  head.  W.,  with  a\  1.  Middle  fork,  heavily  struck, 
held  at  ear,  0.  A^  fork,  when  heavily  struck,  7" ;  c^,  when 
heavily  struck,  -\-.  With  the  conversation  tube,  whisp.  O; 
con.v.  is  well  heard,  but  the  other  ear  cannot  be  excluded. 
Temp,  on  operating  table,  37.25.  After  the  dressing,  pa- 
tient took  soup  without  vomiting.  One-half  hour  later, 
emesis  once.  Temp,  does  not  reach  38.0.  A  labyrinth  op- 
eration was  considered,  but  since  the  temp,  did  not  reach 
38.0,  it  was  not  performed, 

Feb.  10 :  Ny.  rotat.  1.,  less  on  looking  to  the  r.  than  yes- 
terday. No  emesis.  'Feels  well.  Diplopia,  with  images 
above  each  other.    Temp.  37.4. 

Feb.  11 :  Ny.  rotat.  1.  still  very  large.  Less  than  yester- 
day, but  still  present  with  every  position  of  the  eyes.  No 
emesis.    Still  diplopia. 

Feb.  12:  No  diplopia.  Ny.  rotat.  1.  gone  when  looking  to 
r.    Feels  well.    Temp.  37.4. 


CASE  HI  STORIES  227 

Feb.  13 :  Xy.  rotat.  1.  no  longer  present  on  looking  to  r., 
but  still  present  on  looking  to  1.  With  head  bent  backward 
and  eyes  slowly  closed,  the  right  eyelid  is  noticeably  weaker. 
Temp,  from  now  on  noimal. 

Feb.  14:  Ny.  rotat.  1.  on  looking  forward  only  a  trace; 
on  looking  to  the  r,,  none.  Only  a  little  vertigo,  no  diplopia. 
Dressing.  Wound  granulating  nicely.  But  little  dis- 
charge. 

Feb.  15 :  Ny.  rotat.  1.  now  only  on  looking  to  1.  Patient 
says  he  again  has  vertigo  and  diplopia  in  the  forenoon, 
after  he  gets  up,  but  no  change  in  the  ny.  P.M. :  No  ver- 
tigo or  diplopia.    Feels  comfortable.    Gets  up. 

Feb.  16:  Ny.  rotat.  1.  only  on  looking  to  1.  Feels  well. 
Is  up. 

Feb.  18 :  Ny.  rotat.  1.  only  on  looking  to  1.,  but  with  some 
vertigo. 

To  Feb.  23 :  Feels  w^ell  and  goes  about  with  steady  gait. 
Patient  says  that  on  going  to  the  eye  clinic,  where  he  was 
sent  yesterday,  he  had  the  sensation  of  falling  forward. 
At  the  eye  clinic  there  was  found  some  diplopia,  in  that,  on 
looking  to  the  extreme  right,  he  saw  the  finger  used  for 
fixation  "lengthened."  There  was  also  a  tendency  to  see 
double  images  one  above  the  other. 

107.  E.  H.  Age  18.  Bookbinder's  apprentice.  Admitted 
Feb.  22, 1910. 

Anamnesis:  Patient  has  had  a  diseased  r.e.  since  child- 
hood, with  otorrhoea  up  to  one  year  ago.  Two  months  ago 
the  I.e.  began  to  discharge,  continuing  until  now.  No  head- 
ache, no  emesis,  no  vertigo. 

Status  praesens:  R.e.:  Has  already  had  a  radical  mas- 
toid. Gholesteatomatous  material  in  the  antrum.  Opera- 
tive scar  over  mastoid.  L.e. :  Drumhead  destroyed.  Ham- 
mer remains.  Mucous  membrane  of  tympanic  cavity  red 
and  swelled. 

Functional  test:  "R.e.:  Con.v.  31/2  m.,  whisp.  1/2  m.,  R.  — , 
Sch.  shortened;  Ci  0,  c^  -f-.    No  fistula  sympt.    Cal.  react. 


228  DISEASES  OF  THE  LABYRINTH 

prompt.  L.e. :  Con.v.  5  m.,  whisp.  1%  m.,  W.I.,  Sch.  normal. 
Xo  fistula  sympt.    Cal.  react,  prompt.    No  spont.  ny. 

Operation,Yeh.2S:  Typical  radical  operation.  The  cav- 
ity is  covered  with  bluish-white  epithelial  masses,  both  at 
the  tegmen  and  backward  over  the  mastoid  process  into  the 
cells  and  to  the  middle  of  the  mastoid  process.  After  re- 
moval with  the  curette,  there  is  visible,  lying  in  the  course 
of  the  horizontal  semicircular  canal,  a  furrow,  about  I/2  cm. 
in  size.  Pressure  here  causes  no  ny.  In  the  posterior  part 
of  the  antrum  and  from  there  backward  the  exposed  dura 
appears  of  a  whitish  color.  Plastic.  Immediately  after  the 
operation,  severe  vertigo,  falling  movements  to  the  left  and 
violent  vomiting.  He  cannot  possibly  sit  up.  In  the  eve- 
ning there  is  severe  horizontal  ny.  to  the  r.  (toward  the  un- 
operated  ear). 

Mch.  1 :  Ny.  somewhat  less ;  retching  less.  With  the  ex- 
clusion apparatus  in  r.  ear,  loud  voice  is  perceived  by  I.e. 

Mch.  2:  Ny.  much  less;  no  emesis  since  morning;  no 
headache.  Words  spoken  moderately  loud  are  perceived  by 
I.e.  at  1/2  J3a.  with  exclusion  apparatus  in  r.e. 

Mch.  5 :  Only  a  trace  of  ny. 

Mch.  7 :  First  change  of  dressing.  Wound  appears  nor- 
mal. 

Mch.  21 :  Transferred  to  O.P.  Dept.  Ny.  and  vertigo  en- 
tirely gone.    Temp,  has  been  normal  throughout. 

108.  R.  S.  Age  12.   Schoolboy.   Admitted  Aug.  12,  1910. 

Anamnesis:  Measles  in  sixth  year.  Since  then,  otor- 
rhoea.  Now  and  then  headache  and  vertigo.  No  nausea 
or  vomiting.    Temp.  36.8. 

Status  praesens:  L.e.:  Normal.  R.e.:  Drumhead  totally 
destroyed.  Tympanic  cavity  filled  with  granulations.  Pus 
from  antrum,  from  which  project  granulations.  Ossicles 
not  visible. 

Functional  test:  Con.v.  (tested  with  exclusion  appa- 
ratus) 1  m.,  whisp.  2  cm.;  W.  in  head,  R.  — ,  Sch.  short- 
ened, Ci  0,  c^  +.  No  spont.  ny.  No  fistula  sympt.  Cal. 
react,  prompt. 


CASE  HISTORIES  229 

Operation,  Auo;.  14  (Dr.  Froeschels) :  Typical  incision. 
Sinus  lies  very  far  forward  and  is  laid  bare  over  an  area 
the  size  of  a  hempseed.  Antrum  is  deep  and  small,  mastoid 
sclerosed.  Over  the  horizontal  canal,  which  appears  no- 
ticeably small  and  rough,  is  a  black,  punctate  depression. 
Pressure  here  causes  no  eye  movements.  Granulations  over 
the  facial  toward  the  oval  window,  While  sponging,  the 
facial  muscles  twitched  three  times.  Plastic  after  Pause. 
Wick.  A  caseous  abscess  on  the  chin  opened.  Immediately 
upon  awakening,  the  corneal  reflex  on  both  sides  is  alike. 
At  7  o'clock  P.  M. :  Marked  rotat.  ny.  1,  of  third  degree.  Pa- 
tient complains  of  vertigo.  Lies  upon  1.  side.  Typical  laby- 
rinthine emesis.  Temp,  normal.  Hearing  of  operated  ear, 
tested  with  exclusion  apparatus,  is  1  m.  for  con.v.  through 
bandage.  10  P.M. :  Condition  the  same,  but  hearing  acuity 
has  fallen  to  l^  m. 

Aug.  15 :  Ny.  perhaps  somewhat  weaker,  but  still  of  the 
third  degree.  Patient  slept  well.  Less  vertigo  and  emesis. 
Lies  upon  the  left  side.  Con.v.  only  i/^  m.  7  P.  M. :  Ny. 
decidedly  less.  Hearing  the  same.  Feels  relatively  well. 
Temp.  37.2. 

Aug.  16:  Ny.  diminishing,  but  still  of  the  third  degree. 
Hearing  the  same.  No  emesis.  Patient  lies  at  times  on 
his  back.  Evening:  Ny.  rotat.  toward  the  unoperated  side, 
only  of  the  second  degree.    Lies  on  his  back.  Temp,  normal. 

Aug.  17 :  Ny.  is  small.  Hearing  perhaps  better.  Feels 
well.  No  vertigo.  Free  from  temp.  Complains  of  pain  in 
throat. 

Aug.  18:  Ny.  is  small  and  only  during  abduction.  The 
number  of  oscillations  is  limited.    Vertigo  still  present. 

Aug.  19 :  Ny.  still  further  diminished.  Hearing  positive 
at  15  cm.  Patient  reads  the  papers  and  is  free  from  vertigo. 

Aug.  20 :  Change  of  dressing  shows  everything  to  be  in 
good  order.  Hearing  is  positive.  Cal.  react,  prompt. 
Temp.  37.0. 

Aug.  21 :  No  vertigo.  No  ny.  on  lying  upon  his  back,  but 
on  sitting  up,  ny.  rotat.  1.,  with  some  vertigo.    Temp.  37.6. 


230  DISEASES  OF  THE  LABYBIMH 

Aug.  22 :  Temp.  36.2  to  37.3. 

Aug.  23:  Because  he  no  longer  has  ny.  or  vertigo  and 
feels  entirely  well,  patient  is  allowed  to  go  about.  Imme- 
diately he  has  severe  emesis  and  is  forced  to  go  to  bed 
again.  Examination  shows:  Severe  ny.  rotat.  r.  (to  the 
affected  side).  The  ny.  is  very  large  and  rotatory.  Pa- 
tient takes  the  1.  lateral  position  in  bed.  Dressing  removed. 
He  is  totally  deaf  in  the  1.  ear.  Cal.  react,  cannot  be  ob- 
tained. Headache  and  slight  rigidity  of  the  neck.  Pulse 
105.  Temp,  normal.  After  two  hours  the  condition  is  the 
same.  Severe  vomiting.  He  complains  of  headache  and 
weakness.  Severe  vertigo,  ny.  to  affected  side,  sliglit  stiff- 
ness of  neck  and  sensitiveness  to  pressure  over  cervical 
vertebrae.  No  other  symptoms  of  meningitis. 

Operation,  Aug.  23  {Ruttin) :  Wound  opened  and  granu- 
lations removed.  The  inner  wall  of  the  tympanum  curetted 
under  most  careful  inspection.  Stapes  not  present  in  the 
oval  window.  The  probe  enters  the  empty  window  easily. 
Labyrinth  opened  from  behind,  after  exposure  of  the  dura 
of  the  posterior  fossa.  This  is  normal.  The  sinus  lies  ex- 
posed for  an  area  the  size  of  a  lentil  and  is  normal.  The 
dura  of  the  middle  fossa  is  exposed  and  is  normal.  Eve- 
ning: Ny.  rotat.  1.  Vomiting.  Headache.  Pulse  104.  Ver- 
tigo less. 

Aug.  24 :  Ny.  rotat.  1.  of  third  degree.  Lies  upon  1.  side. 
Vertigo  not  very  severe.  No  headache.  Occasional  pains 
in  the  wound.  Notwithstanding  repeated  and  careful  in- 
spections during  the  day,  there  is  no  change  in  the  ny.  Cer- 
tainly there  is  no  ny.  rotat.  r.    Temp.  38.2. 

Aug.  25:  Temp.  37.4.     Aug.  26:  37.5. 

Aug.  28:  Feels  well.  No  ny.  No  headache.  Dressing 
changed.  Wound  in  very  good  condition.  Little  discharge. 
Swelling  of  the  posterior  cervical  glands  r.,  with  pain. 
Temp.  37.3. 

Aug.  29:  No  ny;  no  headache.    Temp.  38,4. 

Aug.  30:  Wound  runs  a  normal  course.  No  ny.,  no  ver- 
tigo. Feels  well.  Spends  the  entire  day  out  of  doors. 
Temp,  from  now  on  normal. 


LIST  OF  AUTHORS 


Abel,  8 

Alexander,  72,  85,  88,  89 

Alt,  86 

AspissoFF,  23 

Barany,  2,  3,  4,  8,  15,  17,  18,  20,  23, 

45,  49,  51,  55,  61,  92 
Beck,  6,  21 
Bezold,  2,  38,  78,  79 
Block,  23 
BoNDY,  45,  58,  90 
Bbieger,  76 
Bblenings,  6,  8,  24 
Buys,  6 

EWALD,  8,  10,  18 

Fechneb,  24 

Flourens,  5 

FoEN,  23 

Freitag,  84 

Frey,  68 

Friedrich,  29,  38,  56,  84 

Hammerschlag,  68 
Hegexer,  32,  38 
Hertzfeld,  88 
Herzog,  40,  45,  87 
Hinsberg.  71,  78,  84 
HOFER,    20 

Jansen,  67,  84 

Kallmann,  22 

KiPROFF,    6 

KtJMMEL,  78,  79 


Lance,  20,  38 
Leidler,  17 

I 

Marx,  79,  87 
Meyer,  29,  86,  87 

Xager,  38,  87 

Neumann,  2,   3,  39,   41,  68,  72,  79, 
83,  92 

PoLiTZER,  23,  32,  50,  75,  86,  87 

RiNNE,   2 

RuTTiN,  32,  38,  80,  85 

Scheibe,  33,  75 
Schmiegelow,  44 
schwabach,  2 
Shrapnell,  73 

SlEBENMANN,   38,   87 

Stein,  27 
Stransky,  55 

Tractmann,  68 

Uffenrode,  87 

Urbantschitsch,  E.  31,  38,  41,  74,  90 
V.  54,  72 

Valsalva,  23 
Voss,  2,  86 

Wageneb,  91 
Wanner,  3,  75 
Weber,  2 
Whitehead,  84 
Whittmaak,  38 
Wojatschek,  6,  88 


Abscess,     cerebellar,    57, 
65,  91 

of  temporal  lobe,  91 

otogenous,   93 
Acuteness  of  hearing,  44 
After-nystagmus,    13 
Antrotomy,  78 
Aspissoff's  device,  23 


INDEX 

Barany's  fixation  appa- 
ratus,   17 

procedure,   3 

rubber  l>ell.  23,  61 
Bezold's  method,  2 
Bloch's  device,  23 
Caloric  irritation,   18 

reaction,  22,  45,  86,  89 

test,   21,  92 

231 


Cartesian    suspension   of 

eyeball,  5 
Case  histories,  98 
Cholesteatoma,     32,     53, 

54,  73,  87 
Cochlea,  opening  of,  70 
Compensation,  37 
Conversation  tube,  2 


232 


INDEX 


Diminution  of  hearing, 
28 

Edelmaxx's  continuous 
tone  series,  2 

Emesis,  34,  41,  42,  77, 
89,  94 

Endolvniph,  movement 
of,  37 

effective,  37 
less  efTective,  37 

Enforced  decubitus,  42 

Equilibrium,  disturb- 

ances of,  25,  28,  34, 
41,  42,  77,  89 

Ewald's  law,   18 

Examination,  cochlear,  1 
functional,    1 
vestibular,  1,  3 

Exclusion   apparatus,  2 

Exposure  o  f  Traut- 
mann's  triangle,  68 

Facial  ridge,  undermin- 
ing of,  69 

Fechner's  law,  24 

Fever,  55 

Fistula  test,  8,  23,  25, 
50,  92 

FoEX  air  apparatus,  23 

Headache,  94 
HiNSBERG  method,  71 
Horizontal    circular    ca- 
nal, undermining  of, 
69 

Labyrinth,  injuries  of, 
77 

migratory  diseases  of, 
88 

necrosis  of,  38 

oedema  of,   85 

operation,    technic    of, 
.       67 

typical  radical,  68 

ossification  of,  50 

probe,    pliable,   70 

purulent         inflamma- 
tion  of,   86 

sequestration     of,     38, 
50 

suppuration  of,  87 

Labyrinthitis  and  brain 
abscess,   91 


anamnesis,  40 
circumscribed,    28,    35, 

60,  73 
diffuse     purulent,     28, 
35 

latent.  35,  66,  74 
manifest,    35,    42, 

64,  74 
serous     secondary, 
28,  35,  63,  74 
etiology,  31 
pathology,  28 
post-operative,  85,  89 
purulent,   41 
serofibrinous,  86 
serous  induced,   85 
spontaneous,  45 
symptoms,  34 
present,  41 
termination,   73 
therapy,  59 
Laermapparat,   2,   27 
LrcAE-DENNERT  test,  2 

Mastoiditis,   87 
Measles,  33 

Mechanical    irritation,  23 
Meningitis,  43,  63,  76,  92 

post-operative,    57 
Metastasis,    suppurating, 
-  57 

Neumann's  method,  3 
Nystagmography,  6 
Nystagmus,  3,  28,  34,  41, 
43,  89,  92,  94 

associated  of  Stran- 
SKY,  55 

caloric,  54 

degree  of,  6 

direction  of,  5 

exaggerated,   95 

extraordinary,   95 

fistula,   54 

of  the  third  degree,  7, 
42 

production  of,  by 
physiological  stimu- 
li, 8 

reversed  aspiration,  51 
compression.    51,    54 

turning,  48,  77 

typical,   51 
aspiration,   51 
compression,  51 


Otitis,   acute,   85 
chronic,  85 

Panotitis,  87 
Panse  plastic,  70 
Paralabyrinthitis,    34 
Paralysis,  facial,  38 
Paresis,  facial,  38 
Politzer  bag.   23,   50 
Polyp,   54 
Position     of     preference, 

42 
Pyaemia,  65 

Reaction,  caloric,  35 

rotation,  35 
RiNNE  test,  2 
Roentgen  rays,  73 
Rotation  stimulus,  8 

Scarlet  fever,  33 
SciiWABACH  test,  2 
Stapes  luxation,  80 
Statistics,  81 
Stimuli,  adequate,  24 

caloric,  24 

inadequate,   24 

mechanical,  25 

relative  value  of,  24 

rotation,  25 

turning,  25 
Strabismus,  18 

Tinnitus,  28,  34,  41 
Tuberculosis,   32,   45,  57, 

93 
Tumor,  93 
Tuning   fork,    2 
Turning  reaction,  46,  86 

stimulus,    8 

test,  92 

Unhealed    radical    opera- 
tion, 85 

V'alsalva  method,  23 
Vertigo,   28,    34.    40,    77, 

89 
Vestibularausschaltungs- 

symptom,  35 
Vomiting,  28 

Wanneb's  method,  3 
Weber  test,  2 
Wick  drain,  70 
Zwangslage,  42 


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